Anatomy Flashcards
1)Triangles of the neck
2) Structures within triangles
1) Anterior - Horizontal ramus of mandible, Midline, SCM
Posterior - middle 1/3 Clavicle, trapezius, SCM,
Roof - Investing Fascia
Floor - Prevertebral fascia
2) Anterior -
Muscles - Supra + (Stylohyoid, digastric, myohyoid, geniohyoid) Infra (Omohyoid, sternohyoid, sternothyroid, thyrohyoid) hyoid muscles
Vascular - CCA, Carotid bifurcation, IJV
Nerves- VII, IX, X, XI, XII
Posterior -
Muscles - Omohyoid (Inferior belly), Vertebral muscles (scalenes, splenius, capitis, levator scapulae)
Vascular - EJV (empties into SCV), Subclavian Art (between ant. and mid. scalen) + Vein, Transverse Cerv. Art + Vein, Suprascapular ARt + Vein
Nerves - CN XI, Cervical Plexus, Phrenic Nerve, Brachial Plexus
1) Subdivisions
2) Contents
1) Carotid - Posterior belly of digastric, Medial border of SCM, Superior belly of omohyoid
Submental - midline, Anterior belly of digastric, hyoid bone
Submandibular - Anterior belly of digastric, Posterior belly of digastric, mandible
Muscular - Hyoid, omohyoid + SCM, Midline
2)
Muscles - Supra + (Stylohyoid, digastric, myohyoid, geniohyoid) Infra (Omohyoid, sternohyoid, sternothyroid, thyrohyoid) hyoid muscles
Vascular - CCA, Carotid bifurcation, IJV
Nerves- VII, IX, X, XI, XII
1) Subdivisions
2) Contents
1) Occipital Triangle- SCM, trapezius, Inf. belly of omohyoid
Subclavian triangle - SCM, mid 1/3 clavicle, Inf. belly of omohyoid
2)
Muscles - Omohyoid (Inferior belly), Vertebral muscles (scalenes, splenius, capitis, levator scapulae)
Vascular - EJV (empties into SCV), Subclavian Art (between ant. and mid. scalen) + Vein, Transverse Cerv. Art + Vein, Suprascapular ARt + Vein
Nerves - CN XI, Cervical Plexus, Phrenic Nerve, Brachial Plexus
Suprahyoid Muscles
Name them, their attachments and innervation
1) Stylohyoid
Styloid process of temporal bone –> lateral hyoid
Innervated by a branch of CN VII
2) Digastric
2 bellies.
Anterior (Inferior Alveolar Nerve - CNV3) - digastric fossa of mandible.
Posterior (Facial Nerve) - styloid process of temporal bone.
Two bellies communicate via intermediate tendon which is trapped by a fibrous sling on thy hyoid bone.
3) Mylohyoid
Mylohyoid line of mandible –> hyoid bone.
Innervation from Inferior Alveolar Nerve of CNV3
4) Geniohyoid
Mental spine of mandible –> hyoid bone
C1 Nerve roots (Travel with CNXII)
Infrahyoid Muscles
name them, their attachments and their innervations
Blood supply from Sup. + Inf. Thyr. Arteries
DEEP
1) Thyrhoyoid
Thyroid cartilage –> hyoid bone
Innervated C1 (travels within CNXII)
2) Sternothyroid
Manubrium –> thyroid cartilage
Innervated by Ansa Cervicalis (C1-C3)
SUPERFICIAL
3)Sternohyoid
Sternum/SCJ –> hyoid bone
Innervated by Ansa Cervicalis (C1-C3)
4) Omohyoid
Scapula (Inferior belly) –> hyoid (superior belly) via intermediate tendon anchored to deep cervical fascia
Innervated by Ansa Cervicalis (C1-C3)
Submandibular Gland
1) Structures at risk during excision + deficit
2) Innervation
1) Lingual Nerve - Ipsilateral taste / sensation loss of anterior 2/3 tongue
Hypoglossal Nerve - Ipsialteral paralysis of the tongue
Facial Nerve (marginal Mandibular branch) - Ipsilateral weakness of lower lip and chin
2) Parasympathetic - CNVII –> Chorda tympani –> Then travels with lingual nerve before synpasing at submandibular ganglion. More volumous secretions
Sympathetic - Superior Cervical Ganglion then plexus follows arteries. Less volumous more enzyme rich secretions.
1) Extrinsic Muscles (attachments + Innervations)
2) Intrinsic Muscles (Innvervations)
1) Extrinsic:
Genioglossus - Mandible –> Hyoid (+all of tongue)
Innervated by CN XII
Hyoglossus - Hyoid –> tongue (CN XII)
Styloglossus - Styloid process –>tongue (CNXII)
Palatoglossus - Palatine aponeurosis –> tongue (CNX)
2) Intrinsic Muscles
Superior longitudinal, inferior longitudinal, transverse + vertical
All innervated by CNXII
Muscles attaching at 1-8
Ligaments 9-11
1 - Suprapinatous 2 - subscapularis 3 - Biceps (short) + Corachobrachialis
4 - Pec Minor 5 - Omohyoid 6 - Serratus Anterior
7 - Subscapularis 8 - Triceps (long)
9 - Coracohumeral ligament 10- coraco-acromial ligament 11 - suprascapular ligament
Muscles 1 -14
ligament 15
1. Infraspinatous 2. Levator Scapulae
3. supraspinatous 4. Trapezius 5. Deltoid
6 Supraspinatous 7 Infraspinatous 8 Teres Minor
9 Long head triceps 10+11 - Teres Minor
12 - Teres Major 13 - Lat Dorsi 14 - Rhom. Major
15. Inferior Scapular Ligament
1) Long head biceps
2) Trapezius (Attach/Innervation)
3) Lat Dorsi (Attach/Innervation)
4) Levator Scapulae (Attach/Innervation)
5) Rhomboids (Attach/Innervation)
1) Supraglenoid tubercle travels within the capsule
2) Skull, nuchal ligament + C7-T12 Spinous processes –> Acromion, Scapular spine + clavicle
Accessory Nerve
3) Spinous Processes T7-T12, iliac crest, inferior three ribs + lumbar fascia –> Intertubercular sulcus of humerus
Thoracodorsal nerve
4) C1-C4 spinous processes –> Medial scapular border.
Dorsal Scapular Nerve
5) C7-T1(Minor) T2-T5 (major) –> medial scapula
Dorsal scapular nerve
1-9
1. Piriformis 2. glut. max 3. Quadr. Femori
4- origin of semitendinosus, biceps femoris
5 - gracilis 6 - semitendinosus 7. semimembranosus
8. Gracilis 9. Long head of biceps femoris
10-19
10. Sciatic Nerve 11 Post. Cutaneous Nerve of thigh
12 ischial tuberosity 13 poplit. artery
14. polit. vein 15. SSV
16. Tibial Nerve 17. Common peroneal Nerve
18. Peroneal communicative nerve 19. sural nerve
1-15
1. Piriformis 2. Quadratus Femoris
3. Origin of semitendinosis/ bicep fem. 4. Gracilis
5. Long head bicep fem. 6 Semitendinosis
7. Short head bicep fem. 8. Semimebranosous
9. Post. Cut. Nerve of thich 10. Sciatic Nerve
11. Ischial Tuberosity 12. Pop. ARt.
13. Pop. Vein 14. Srural Nerve 15. SSV
Name all muscles, attachment and innervation of anterior thigh
Blood Supply
Sartorius - ASIS –> Medial tibia (pes anserius) femoral nerve
Pectineus - Anterior pelvis (pectineal line) –> posterior femur (pectineal line) femoral/obturator nerve
Psoas Major - Lumbar vertebrae has common tendon with iliacus –> lesser trochanter of femur (L1-L3 nerve roots)
Iliacus - Iliac fossa has a common tendon with psoas maj. —> lesser trochanter of femur (femoral nerve)
Quadriceps Muscles: (common insertion onto patella via quadriceps tendon) femoral nerve
Rectus Femoris - Ridge of iliac portion of acetabulum (superior to acetabulum)/ anterior inferior iliac spine
Vastus Medialis - Intertrochanteric line/medial linea aspera
Vastis intermedius - Anterior/Lateral Femoral Shaft
Vastus Lateralis - Greater trochanter/lateral linea aspera
Profunda Femoris
Name all muscles, insertions and innervations of the posterior thigh
Blood Supply
Hamstrings -
Biceps Femoris -
Long head - Ischial tuberosity. tibial portion of sciat.
Short head - Linea aspera. fibular portion of sciat.
Common tendon inserts to head of fibula
Semitendinosus - ischial tuberosity to medial tibia. tibial portion of sciat.
Semimembranosus (deep to semitend.) - ischial tuberosity to medial tibial condyle. tibial portion of sciat.
Blood Supply - Inferior gluteal artery + profunda femoris artery
Name all muscles, insertions and innervations of the medial thigh
Blood Supply
Adductor Magnus
Adductor port. - Inferior pub. rami + ischial rami –> linea aspera. obturator nerv.
Hamstring portion - Ischial tub. –> extends distally attaching to supracondylar line of fem. + adductor tubercle. tibial port. of sciatic n.
Adductor Longus -Pubis –>linea aspera. obturator n
Adductor Brevis (beneath longus)- pubis + inf. pubic rami –> linea aspera (prox. to longus) obtur. nerv.
Obturator Externus - obturator foramen –> post. aspect of greater. troch. obturator nerve
Gracilis - pubis + inf. pub. rami –> pes anserius (in between sartorius and semintendinosis) obturator nerve.
Blood supply - Obturator artery + perforating branches of the profunda femoris
1-11
1. Pec Minor 2. deltoid 3. Pec major
4. Triceps 5. Biceps (long) 6. Biceps (short)
7. Corachobrachialis 8. Teres Major 9. Subscapularis
10. Lat. Dorsi 11. Serrat. Ant.
12- 19
12. lat 1/3 clavicle 13. Axillary Vein.
14. Thoracoacromial Trunk
15. Circumflex scapular artery
16. Subscapular Art. 17. Axillary Artery
18. Thoracodorsal artery 19. Brachial Art.
20-28
20 - Medial Cord 21 - Lateral Cord
22- Musculocutaneous n. 23 - Median n.
24 - Radial n.
25. thoracodrosal n. 26. median n.
27. Ulna N. 28. Medial cutaneous n. of forearm
i) Gross heirarchy
ii) Describe formation from spinal cord to the plexus
iii) Describe derivatives of trunks
iv) Describe contributions to the cords and relative positions
i) Roots > Trunks > Divisions > Cords > Branches
ii) Derived from anterior rami of C5-T1 spinal nerves. They pass in between the anterior and medial scalene muscles just superior to the subcalvian artery
iii) Superior - C5-C6
- *Middle** - C7
- *Inferior -** C8-T1
Trunks cross laterally through the posterior neck triangle
iv) Cords are named relative to axillary artery. Trunks divide into ant. and post. divisions and enter axilla.
Lateral - Anterior Division of Superior + Middle Trunk
Posterior - Posterior Division of all trunks
Medial - Anterior Division of Inferior Trunk
Brachial Plexus 2
i) Major Branches of the brachial plexus
ii) Minor branches of the brachial plexus and where they come from
i)
Lateral Cord - Musculocutaneous Nerve (C5-C7)
Posterior Cord - Axillary Nerve (C5-C6), Radial Nerve (C5-T1)
Medial Cord - Ulnar Nerve (C8-T1)
Medial + Lat. Cords - Median Nerve (C5/6-T1)
ii)
Roots - Dorsal Scap. Nerv (C5 - Rhomboids)
Long Thor. Nerve (C5-7 - Serratus Ant.)
Trunks - Suprascap. Nerv. (Upper Trunk- Supra+ Infraspinatus)
Nerve to Subclavius (Upper Trunk - subclavius)
Lat. Cord - Lat. Pect. Nerv. (Pec Major)
Med. Cord - Med. Pect. Nerv (Pec Min. + Maj)
Med. Cut. Nerve of forearm
Med. Cut. Nerve of arm
Post. Cord - Thoracodorsal Nerv. (Lat. Dorsi)
Sup. Subscapular Nerv. (subscapularis)
Inf. Subscapular Nerv. (Teres Maj. + subscapularis)
The Axilla:
i) Boundaries
ii) Passageways exiting the axilla
iii) Contents of axilla
i)
Apex - Posterior clavicle, Sup. Scapula, First Rib
Latera- Intertubercular groove of humerus
Medial - Serratus anterior + thoracic wall
Posterior - lat dorsi, teres maj., subscapularis
anterior - pec major, minor, subclavius
ii)
1) Exit into upper arm (Lat. and inf.)
2) Qaudrangular Space
Lat. - Humerus, Med. - Triceps long head, sup. - teres minor. inf. - teres major
Transmits - Axillary n., post circumflex humeral vessels
3) Clavipectoral Triangle
Inf - pec Major Sup Lat. - Deltoid, Sup Med. - Clavicle
Transmits - Cephalic Vein, Deltoid branch of thoracoacromial art.
4) Lateral Triangular Space
Sup - Teres Maj Lat - Humerus med - Long head triceps
Transmits - Radial Nerve, Pronfuda brachii artery
iii) Axillary Contents:
- Axillary artery + branches
- Axillary veins + tributaries
- Axillary LNs
- Biceps (short) head, and corachobrachialis
Subclavian Artery
i) Gross route
ii) Branches
i) R- arises from brachiocephalic trunk. RLN winds around this on the right side
L - Directly from aortic arch
1st part - Aorta –> Anterior Scalene
2nd part - Posterior to anterior scalene
3rd part - Anterior scalene to first rib
ii) VIT CD
1st -
Vertebral (Enter C6 transverse process travelling superiorly through foramen transversarium before enterring foramen magnum where they unite)
Internal Thoracic Artery (Intercostal branches, breast perforators, terminates as superior epigastric)
Thyrocervical trunk ( Inferior thyroid, Suprascapular, transverse cervical art.)
2nd - Costocervical Trunk (Sup. intercosta, deep cervical)
3rd Dosal Scapular Artery
Axillary Artery
i) Gross Route
ii) branches
i) Continuation of subclavian art. as it passes border of first rib. beomes the brachial artery after the lower border of teres major
Divisible into three parts
1st part - Proximal to pec minor
2nd part - Posterior to pec minor
3rd part - Distal to pec minor
ii) Screw the Lawyer, Save a patient
1st part - Superior Thoracic Artery
2nd part - Thoracoacromial artery (Pectoral, Acromial, Clavicular + Deltoid)
Lateral Thoracic Artery
3rd Part - Subscap. art.
Ant. + Post. Circumflex arteries
Ear
i) Middle Ear Muscles
ii) Parasympathetic Nerves running through/near ear
i) Tensor Tympani - Auditory tube –> handle of malleus
Mandibular Nerve V3
Dampens sounds
Stapedius - Pyramid walls –> Stapes
VII
Stabilises of stapes
ii) CNVII - Parasympathetic nerves to lacrimal glands.
Gives off the greater petrosal nerve to the pterygopalatine ganglion. From here postganglionic fibers travel with V2 branches to reach nasolacrimal glands/epithelium.
Gives off the chorda tympani (joins lingual nerve) which synapses with the submandibular ganglion and innervates submandibular gland.
CNIX - Tympanic branch innervates tympanic plexus. CNIX fibers then form lesser petrosal nerve synapsing with the otic ganglion. postganglionic fibers then travel with auriculotemporal nerve (V3 Branch) to innervate parotid + sublingual glands.
Label 1-13
1. Helix 2. Scapha 3. Tubercle 4. Antihelix
5. Antitragus 6. Earlobe 7. Tragus
8. Intertragic Notch 9. External Meatus (cartilage)
10. Crus of helix 11. Crus of antihelix
12. Triangular fossa 13. Mastoid Process
Label 14-25
14. Mallues 15. Incus 16. Stapes
17. Manubrium 18. Malleus 19. Pars Flaccida
20. Chorda Tympani 21. Incus 22. Umbo
23. Pars tensa 24. Annulus Fibrosis 25. cone of light
Grossly Describe External Ear
i) Visible
ii) Describe external accoustic meatus
iii) Tympanic Membrane
iv) innervation of the external ear
i) Auricle - Visible part of the ear.
Upper auricle is cartilagenous while the lobe is not cartilagenous.
Helix is the outer cartilagenous rim of auricle while the anti-helix is the inner cartilagenous rim
Concha- Depression in middle ear continuing into the external accoustic meatus
Tragus and anti-tragus - immediately at entry to the external accoustic meatus
ii) External accoustic meat. runs from concha to the tympanic membrane in an s shape. external 1/3 - cartilaginous whereas the internal 2/3 are formed by the temporal bone
iii) Tympanic memb. - Connected to temporal bone by fibrocartilagenous ring.
Handle of malleus attaches at umbo. Pars tensa spreads radially from the handle of malleus whereas pars flacidda is superior to the handle
iv)
Cervical Plexus - Greater auricular nerve + Lesser occipital nerve both supply skin of auricle
Auriculotemporal nerve (CNV3), Facial Nerve + Vagal nerve supply skin of auricle and external accoustic meatus
Middle Ear
i) Gross Description
ii) Borders
iii) Bony components
i) Begins at tympanic membrane. Medially is the tympanic cavity whereas superiorly is the epitympanic recess (next to the mastoid air cells)
Eustachian tube connects middle ear (ant. wall) to nasopharynx (lat. wall).
ii)
Roof - Petrous temporal bone adjacent to middle cranial cavity
Floor - Petrous temporal bone. IJV adjacent
Lateral wall- Tympanic Membrame
Medial wall - Laterally borders inner ear. Facial Nerve Bulge
Anterior Wall - Two openings - Auditory tube + tensor tympani. ICA adjacent
Posterior Wall - Adjacent to mastoid cavity. Mastoid aditus allows communciation between middle ear and mastoid air cells
iii) Bony components transmit sound from tympanic membrane to the oval window
Malleus–> Incus–> Stapes
INner Ear
i) Gross anatomy
ii) Describe balance organs
iii) Describe auditory organs
i) Grossly the inner ear is comrpised of the
- bony labyrinth, in the petrous bone formed by cochlea, vestibule (cochlea is anterior and semi circular canals are posterior) and 3 semi-circular canals. Lined by perilymph
- membranous labyrinth is within the bony labyrinth. It is formed from saccule, 3 semi-circular ducts, cochlea duct and utricle. Lined by endolymph
-
oval window is between middle ear and vestibule, round window is betwene the middle ear and part of the cochlear duct
iii) Cochlea houses the cochlea duct. Modiolus is central portion of bone in cochlea which communicates with CN VIII. Spiral Lamina portion of cochlea holds teh cochlea duct in place.
Scala vestibuli superior to each cochlea duct (seperated from each other by reissner’s membrane) and scala tympani inferiorly (seprated by basilar membrance which houses organs of corti [specialised accoustic epithelium]). Basement membrane essentially are the receptors of CNVIII.
iii) Saccule and Urticle in the vestibule responsible for balance. saccule - vertical movement recevies the cochlea duct. urticle -horizontal movement receives the semicircular ducts.
Submandibular Gland 1
i) Location
ii) (Once again) What is at risk during surgery
iii) relation of facial artery and vein to submandibular gland
i) Posterior inferior to horizontal mandibular ramus in digastric triangle.
ii) Marginal Mand. Nerve (Lip droop), Lingual Nerve,
Hypoglossal Nerve
iii) Artery- passes deep to the gland
vein - passes superficial to the gland
Submandiublar 2
1-12
1. Frontalis 2. Obicularis Oculi 3. Temporalis
4+5. Levator Labii Superioris 6. Orbicularis Oris
7. Levator Angular Oris 8. Zyg. Major
9. buccinator 10. Depressor anguli Oris
11. Depressor Labii Inferioris 12. masseter
Submandibualr 3
13-25
13. parotid gland 14. submandibular gland
15. Horizontal body of mandible
16. Facial Artery 17. Sup. Temp. Artery
18. Angular Vein 19. Facial Vein 20. IJV
21. Stenson’s (parotid) duct 22. Temporalis Fascia
23. Facial nerve (upper div.)
24. VII Buccal branches 25. VII Zyg. Branches
The Nose
1-12
1. Frontal Bone 2. Nasal Bone 3. Superior Concha
4. Sphenoid Sinus 5. Pituitary GLand
6. Middle Meatus 7. Hiatus Semilunaris
8. inferior Conchae 9. inferior meatus
10. nasopharynx 11. tubular ridge
12. opening of eustachian tube
The nose
13
13. Adenoid 14. Pharyngeal Recess
15. Salpingopharyngeal fold 16. Pharyngeal isthmus
17. Hard palate 18. Soft palate
19. oral cavity 20. oropharynx
21. palatopharyngeal fold 22. Palatoglossal fold
23. Intrinsic tongue muscles 24. Nares
The nose
1-20
1. inferior meatus 2. inferior conchae
3. Hard palate 4. soft palate 5. Pharyngeal isthmus
6. palatopharyngeal fold 7. palatoglossal fold
8. oral cavity 9. Fungiform papillae
10. Vallate papillae 11. oropharynx 12. lingual tonsils
13. intrinsic tongue muscles 14. Genioglossus
15. geniohyoid 16. epiglottis 17. piriform fossa
18 Vallecular 19. hyoid bone 20 laryngeal inlet
Broad divisions of oral/ nasal cavity:
1) Nasal Cavity
2) Nasopharynx
3) Oral cavity
4) Oropharynx
5) Laryngopharynx
1) Nares–> imaginary line through start of soft palate and base of skull
2) Ends at a line drawn between uvula (end of soft palate and base of skull)
3) Lips to level of anterior epiglottis
4) Anterior border - Line between uvula and anterior epiglottis
Superior - level of uvula
inferior - level of hyoid bone
5) hyoid bone to the level of trachea/oesophageal divergence
Oropharynx
1-13
1. Pituitary Gland 2. sphenoid Sinus
3. Middle Concha 4. Adenoids 5. Nasopharynx
6. Auditory Tube Opening 7. Pharyngeal recess
8. tubal ridge 9. salpingopharyngeal fold
10. Soft palate 11. Uvula/pharyngeal isthmus
12. palatoglossal fold 13. palatopharyngeal fold
Oropharynx
14-26
14. Oropharynx 15. Post. Pharyng. Wall
16. Lingual Tonsil 17. Epiglottis
18. Laryngopharynx 19. Hyoid Bone
20. Vestibular Fold (false cords) 21. Laryng. Sinus
22. Vocal Fold (true cord) 23. Trachea
24. Oesophagus 25. Retropharyngeal Space
26. Piriform fossa
Oropharynx
27-38
27. Anterior arch of atlas 28. Dens 29. C3 Body
30. Basilar ARt. 31. Vertebral art. 32. PICA
33. Pons 34. medulla oblongata 35. Cerebellum
36. 4th Ventricle 37. Cisterna Pontis
38. Central Canal
Anterior Neck Anatomy
1-14
1. Parotid Gland 2. Submandibular Gland
3. masseter 4. Platysma 5. Mylohyoid
6. Anterior Belly Digastric 7. Posterior belly digastric
8. Hyoid Bone 9. Omohyoid (Sup. Belly)
10. Sternohyoid 11.thryohyoid12. SCM
13. Clavicle 14. Deltoid
Anterior Neck Anatomy 2
15 - 30
15. Pec Major 16. Scal. Ant. 17. Scal. Med
18. Inf. belly Omohyoid 19. Levat. Scapul.
20. Semispinal. 21. Facial nerv. 22. Int. Jug Vein
23. Ansa Cervicalis 24. EJV
25. Carotid Sinus 26. ICA + ECA
27. Hypoglossal N. 28. Accessory N.
29. subscapular art. 30. Thyrohyoid Nerve.
What covers the roof + floor of the anterior neck triangle
Roof - Investing fascia
Floor- Visceral Fascia
Larynx
i) Cartilage types in the larynx
i) Epiglottis - Elastic
Thyroid, Cricoid, Aryetonoids, corniculate, cuneiform –> Hyaline
Larynx anatomy
1-9
1. Fungiform Papillae 2. Vallate Papillae
3. Foramen Caecum 4. Sulcus Terminalis
5. epiglottis 6. laryngeal inlet
- *7.** valleculae 8. Posterior Pharyngeal Wall
- *9.** Piriform Fossa
Larynx Anatomy 2
10-18
10. Arytenoid Cartilage / Fold
11. Laryngopharynx 12. Vestiublar Fold ( False Cord)
13. Vocal Fold (true cord) 14. Glottis
15. Cricoid Cartilage 16. Trachea 17. oesophagus
18. Lingual Tonsils
Posterior Triangle
1-13
1. parotid 2. Submandib. LNs
3. posterior belly of digastric 4. Submand. Gland
5. SCM 6. Splenius Capitis 7. Levator Scap.
8. trapezius 9. Scal. medius 10. Scal. Post.
11. ECA 12. Facial Art. 13. CCA
posterior triangle
14. Greater Auricular N. 15. Hypoglossal N.
16. Cervical Plex. 17. Transv. Cerv. N.
18. Brachial Plex (upper trunk)
19. Suprascapular N. 20. Phrenic n.
21. Supraclavicular N. 22. Lesser occipital n.
Accessory N.
i) Course
ii) Innervates
iii) Testing weakness
i) Exits skull vault through Jugular Foramen. Passess deep to SCM and stays near trapezius.
ii) innervates SCM + Trapezium
iii) Trapezius - Shrug
SCM - Resisted turning head (If left turn is weak then contralateral [right] CNXI is damaged)
Parotid Anatomy
1. Orbicularis Oculi 2. Zygomaticus Major
3. Zygomaticus Minor 4. Levator Angular Oris
5. Orbicularis Oris 6. Depressor ANgular Oris
7. Platysma
8. Masseter 9. SCM 10. Parotid Gland 11. parotid duct (stenson’s) 12. Accessory Parotid gland
13. Superficial Temporal Art. 14. Facial ARtery.
15. Facial Vein 16. Angular Vein
17. Facial N. Upper Div.
18. Temporal N. 19. Zygomatic N. 20. buccal N.
21. Marginal Mandib. N. 22. cervical n.
Clavicle
Label 1 - 6
What ataches 7-15
Name articulation 16-17
1. Acromial End 2. Ant. Border 3. post. border
4. conoid tubercle 5. shaft 6. sternal end
7. Trap. 8. Delt. 9. SCM 10. Pec Maj.
11. Subclavius 12. Interclavicular lig
13. Trapezoid portion of coroclavicular lig.
14. Conoid portion of coroclavicular lig.
15. Costoclavicular ligament
16. Sternum ARticulation
17. Acromion Articulation
Subclavian Art.
Define the three parts
Branches and where they arise
Branches of the Branches
i) Parts:
1 - origin to scalenus anterior (medial border)
2 - behind scalenus anterior
3 - from lateral borer of scalenus anterior to 1st rib
ii) Branches:
1st Part - Vertebral, Internal Thoracic, Thyrocervical
2nd Part - Costocervical, Dorsal Scapular
iii) B of Bs
Verebtral - Ant. + Post. Meningeal arteries, 1 x Ant spinal artery, 2 x Post Spinal ARtery, PICA (End as they converge to form basillar artery)
Internal Thoracic Artery - terminates as musculophrenic artery + superior epigastric artery
Thyrocervical Trunk - Inf. Thyroid Ard, Suprascapular art., Transverse cervical art., ascending cervical art.
Costocervical trunk - Terminates as deep cervical artery, sup. intercostal art.
Ribs
i) How do they articulate with sternum
ii) Where is the intercostal bundle?
iii) Which rib has 2 tubercles
iv) Describe relations to the scalene tubercle
i) 1-7 - Have individual costal cartilage
8-10 - Have shared costal cartilage
11-12 - have no costal cartilage
ii) intercostal bundle exists in a groove on the lower surface of the rib
iii) First rib - Scalene Tubercle and costal tubercle
iv) Ant. to the tubercle is the groove for the subclavian vein
Post. to the tbercle is the groove for subclav. art. + lower trunk of brachial plexus
Clavicle
Where do the major muscles attaching to the clavicle attach.
Superior Surface:
Acromial End
- Trapezius (posterior)
- Deltoid (anterior)
Sternal End
- Sternocleidomastoid (posterior)
- Pec Major (anterior)
Inferior Sruface:
- Subclavius muscle
Intercostal
i) Muscles how many are there - name then
ii) Where is the intercostal bundle - name the structures from the top downwards
i) Three
External - Downwards and forwards (inhalation)
Internal - Downwards and backwards (exhalation)
Innermost - Transversus thoracicus (ant.), lateral slips (lat.), subcostalis (post.)
Fibers of internal and external intercostal muscles run in opposite directions.
ii) Run in a groove beneath rib in between the innermost and internal intercostal muscles
(Most Superior) Vein, Artery, Nerve
Label 1-12
1. Thoracic Aorta 2. Thoracic Duct
3. Ayzgous vein 4. Sympathetic trunk
5. Intercostal Vein, 6. Int. ARt. 7. Int Nerve
8. Sup. Intercostal Vein
9. Vertebral Body 10. Vertebral Disc
11. Rib 12. Innermost intercostal muscle
Label 1-19
1. Trachea 2. Inf. Thyroid Vein 3. Trachea
4. R. Main Bronch. 5. L. Main Bronch.
6. Subcarinal LNs 7. Oesophagus
8. Aortic Root 9. Brachiocephalic Trunk
10. Ext. Carotid Art. 11. Subclav. Art.
12. Internal Thoracic ARt. 13. Costocervical Trunk
14. Subclav Art. 15. Common Carotid Art.
16. R Vagus 17. L Vagus 18 R phrenic trunk
19 R Sympathetic trunk
Trachea
i) What level does it originate and divide?
ii) relations of trachea in neck
iii) What are the walls of the trachea made of?
i) Originates at C6 (lower border of cricoid cart.) and divides at T4 (carina is behind angle of louis)
ii)
ant. Thyroid, inf. thyr. vein, sternohyoid, sternothyroid
post. Oesophagus, RLN in oesophagatracheal groove
lat. carotid sheath, lateral thyr. lobes
iii)
Walls of trachea are made of:
- C shaped cartilage anteriorly + laterally
- Membranous wall posteriorly with trachealis muscle
Angle of Louis
i) What vertebral level
ii) What anatomical releavance
i) Level of T4/T5 Vertebrae
ii) Carina, Start+ End of aortic arch
Aygos drains into SVC,
THoracic Duct crosses R -> L behind oesophagus
Division of Sup/Inf Mediastinum
L RLN loops behind aortic arch
Label 1-12
R Lung
1. Upper Lobe. 2. Lower Lobe 3. Middle lobe
4. Apex 5. Base
6. Horizontal Fissure 7. Oblique Fissure
8. impresion of subcl. art.
9. impression of 1st rib
10. impression of azygous vein
11. Right Atrium 12. Pul Arteries
13. Bronchus 14. Pul Veins
Label 1-13
1. Upper Lobe 2. Lower Lobe
3. Apex 4. Lingula 5. Base
6. Oblique Fissure
7. Impression for 1st Rib
8. impression for Subclav. ARt
9. Impression for Aorta
10. Impression for L Ventricle
11. Pul. Art. 12. Bronchus 13. Pul Vein
Pulmonary Artery
i) Course of R Pul ARt.
ii) Course of L Pul Art
i) Arise from pulmonary trunk.
Passes in front of oesophagus
behind ascending aorta/ SVC
then at the root it passes between R Main Bronchus and Upper lobe bronchus
Divides into ther branches (lobar)
ii) Arises from PT. Connected to aortic arch by ligamentum arteriosium.
Passes in front of the descending aorta/ L Main Bronchus
i) Describe the pleural cavity
ii) Describe hiccough reflex
iii) Surface markings of pleura
iv) Surface markings of lung
i) Potential space in between visceral pleura (covering the lungs, vessels, bronchi + nerves) and the parietal pleura (attached to the chest wall - endothoracic fascia) .
ii) HIccough is caused by phrenic nerve (+its distribution) irritation leading to contractions of the daiphragm
iii) 2nd rib - are converged and then diverge again at the 4th rib. 6th rib parasternal 8th rib mid clavicular 10th rib mid axillary 12th rib converge
at erector spinae
iv) 6th rib mid clavicular line 8th rib mid axillary line 10th rib Erector Spinae
Lungs
Label
1. Upper Lobe 2. Midle lobe 3. lower lobe
4. Upper Lobe 5. Lower Lobe 6. Manubrium
7. Diphragm 8. R Lobe Liver 9. L Lobe Liver
10. Falciform Ligament
11. R Apex 12. R Horizontal Fissure 13. R Oblique Fissure 14. L Apex 15. L oblique fissure
16. Int. Thorac. Art. 17. Costal (parietal) Pleura
18. Mediastinal (parietal) pleura
19. Fibrous Pericardium (Superficial to parietal pleura)
20.
Innervation of
Visceral Pleura
Parietal Pleura
Diaphragm
Visceral Pleura - Supplied by vagus nerve
Parietal Pleura - Supplied by intercostal nerves
Diaphragm - Phrenic nerve (C3-C5)
Parietal pleura and diaphragm both have pain receptors whereas the visceral pleura does not.
Diaphragmatic Openings and their occupants, what else goes through diaphragm
Diaphragmatic embyrology - 4 components
i) T8 Caval Foramen (Central tendon)
Contains - IVC + R Phrenic Nerve (L pierces diaphragm directly)
ii) T10 Oesophageal Foramen (R Crus)
Contains- Oesophagus, L Gastric A+V, Vagus trunks
iii) T12 Aortic Foramen (Behind diaphragm)
Contains - Abdominal Aorta, Thoracic Duct, Azygos Vein
iv) L Phrenic Nerve, Splanchnic nerves, Superior epigastric vessels, Sympahetic chain (Behind median arcuate ligament)
Embryologically diaphragm forms from fusion of -
Septum Transversum, Foregut Mesentery, Ingrowth from body wall, Pleuroperitoneal membrane
Septum Transversum forms Central Tendon
Foregut Mesentery forms oesophageal opening + crura
Diaphragm
1. IVC 2. Oesophagus 3. Aorta
4. Renal Art. 5. Coeliac Art. 6. SMA
7. Pericardiophrenic Art. 8. Inf. Phrenic Art.
9. Costal Fibers of diphragm 10. R Crus
11. L Crus 12. Median Arcuate Lig.
13. Central Tendon 14. Sternal Diaphragm Fibers
15. L Renal Vein
Types of diaphragamatic hernias
Through Bochdalek Foramen - Left usually (through pleuroperitoneal membrane)
Through Morgagni foramen - Anterior through xiphoid and costal origin
Can also herniate through - large oesophageal foramen + through deficient central tendon
Mediastinum
i) Divisions of the mediastinum
i) Imaginary line through the sternal angle seperates the superior (to the thoracic arpeture) and inferior (to the diaphragm) mediastinum.
Superior - Anteriorly - Manubrium to sternal Angle
Posterior - T1 - T4 Vertebrae
Anterior - Between sternal angle and diaphragm (anteriorly chest wall, posteriorly the pericardium)
Middle - Pericardium
Posterior - Anteriorly pericardium, Posteriorly vertebrae, superiorly sternal angle, inferiorly the diaphragm
Contents of:
i) Sup Mediastinum
ii) Ant. Mediastinum
iii) Mid Mediastinum
iv) Post. Mediastinum
i) Vessels- Arch of aorta + branches, SVC + tributaries( Azygos, brachiocephalic, supreme intercost., L Sup. intercostal)
Nerves - phrenic (ant. to ant. scalene), R Vagus (Post. to SVC and R main bronch.), L Vagus (Ant. to Aortic ARch and post. to L Main bronchus), Cardiac Nerves, Sympathetic Trunk
Muscles- Sternohyoid, Sternothyroid
Others- Thymus, Trachea, Oesophagus, Thoracic Duct
ii) Sternopericardial Ligaments (+thymus - mainly in children
iii) Vessels- Ascending Aorta, SVC, Pulmonary Trunk
Nerves - Cardiac plexus, Phrenic Nerves
Others - Heart, Tracheobronchial LNs, Primary Bronchi (+carina)
iv) Vessels - Descending aorta + branches (9 paired post. intercostal, 1-2 Paired bronchial arteries, 1-2 unpaired oesophageal arteries, Sup. phrenic arteries), Azygous System
Nerves - L+R Vagus Nerves ( form oesophageal plexus and then as leaving diaphragm converge to form L+R Vagal Trunks), Sympathetic Trunks
Others - Oesophagus (posterior to aortic arch / aorta), Thoracic Duct (Anterior to vertebral bodies),
Describe Azygous System
Importance in IVC Obstruction?
In the posterior mediastinum:
Azygous vein - Formed from R Lumbar + R Subcostal veins. Enters with aorta through aortic hiatus.
Essentially drains the posterior lumbar and thoracic wall
Hemiazygous vein - Formed from L Lumbar L subcostal vein. Enters through L crus of diaphragm. At T8 crosses vertebrae and drains into ayzous vein.
Accessory Hemiazygous Vein - Formed from L 4th-8th intercostal veins. Crosses at T7 to drain into Azygous Vein.
The ayzgous vein empties into the SVC by passing over the R Main Bronchus at the root of the lung.
IVC obstruction - There is collateralisation through the azygous system to the SVC through:
Lumbar Azygous Veins (between renal veins and azygous veins) which form communication between IVC and azygous vein (at its origin)
Heart Anterior
Heart Vasculature:
i) How many Pulmonary Veins are there?
ii) SVC Course?
iii) What is the coronary sulcus?
iv) what are the interventricular sulci?
v) What are the pericardial sinuses?
i) 2 Pairs of pulmonary veins - 1 inferior + 1 superior
all draining into L Atrium
ii) SVC formed by unification of both brachicephalic veins. The SVC travels laterally to the right mediastinum and then pierces the middle mediastinum before emptying into the right atrium.
iii) Groove running circumferentially around the heart ‘seperating’ the atria from the ventricles
iv) Running vertically down the surface of the anterior + posterior aspcts of heart
v) Sinuses are formed from folds of the pericardium.
oblique sinus - on posterior surface of heart
trasnverse sinus - Posterior to the ascending aorta + pulmonary traunk / Anterior to the SVC. Seperates the main arteries/veins
Heart anatomy atria :
i) Divisions of R Atrium
ii) what is the fossa ovalis a remnant of?
iii) gross description of L atrium
i) Divided by the crista terminalis (muscular ridge) into the sinus venarum (posterior to CT) and the atrium proper (anterior to CT) which has pectinate muscles. Coronory Sinus also opens into the right atrium
ii) Fossa Ovalis is a remnant of the foramen ovale in between the R and L atriums on the interatrial
septum.
iii) Posterior border of the heart. Superiorly is the l auricle. Two portions of the L atrium (interior) - posterior is the inflow portion receiving blood from PVs and the anterior is the outflow portion which is lined by pectinate muscles.
Heart Anatomy (Ventricles):
i) Different features of ventricle walls
ii) How many papillary muscles on R ventricle / L VEntricle
iii) What are the outflow tract of R and L Ventricle called
i) Trabeculae Carnae - are a series of muscular elevation predominantly in inflow tracts. Different types are -
Papillary Muscles - are attached to the tricuspid/mitral valve by Chordae Tendinae. They contract to prevent valve prolapse during ventricular systole
Ridges + Bridges (Important example of a bridge is the moderator band of R Ventricle)
Supraventricular Crest - Divides inflow and outflow portion of the R Ventricle
ii) 3 - on right as tricupid has 3 leaflets
2 - on left as mitral has 2 leaflets
iii) Conus Arteriosus - is the outflow tract of the R Ventricle where as the L Vetnricle outflow tract is called the aortic vestibule. Both develop from the bulbus cordis.
Cardiac Conducting System
i) Where is SA node
ii) What is the PR interval caused by?
iii) What happens beyond the AV node? Describe the components
iv) Where might you find pacemaker leads?
i) Sinoatrial Node is in the wall of right atrium near the SVC
ii) PR interval is caused by delayed conduction in the atrioventricular node situated in the atrioventricular septum near the coronary sinus
iii) Immediately after the AV node is the bundle of his within the interventricular septum. This then branches into the Right and Left Bundle.
Right Bundle - Only 1 Fascilce
Left Bundle - Anterior and Posterior fasicle.
The bundles then continue to the apex of the heart from where purkinje fibers begin to extend into the subendocardium disseminating action potential to myocardium.
iv)
Right ventricle lead - practically all devices
Right atrial lead - dual chamber devices
Coronary Sinus lead - Biventricular devices
Pericardium
i) Layers
ii) innervation
i) Fibrous Pericardium - Continuous with central tendon of diaphragm. Non distensible
Serous Pericardium - Seperated into -
Parietal Pericardium
Visceral Pericarium - Also known as the epicardium
ii) Innervated by the phrenic nerve
Coronary Vasculature
i) Describe the coronary arteries
i) Aortic Sinuses are behind the aortic valve leaflets and blood enters this in diastole.
Aortic Sinuses go on to form the:
Left Coronary Artery + Right Coronary Artery
Left coronary artery gives three branches(or four):
Left Anterior Descending (Anterior Inteventricular groove. AKA Anterior Interventricular Artery)
Left Circumflex ARtery (In the coronary sulcus. Gives rise to the L Marginal Artery)
(rarely the posterior interventricular artery)
Right Coronary artery (runs in the coronary sulcus) gives two branches (or one):
Right Marginal Artery
Posterior Interventricular Artery (Post. IV Groove)
ii) Veins eventually drain into the coronary sinus (located posteriorly on the coronary sulcus which in turn drains into the R atrium )
Anterior Veins are the :
Great Cardiac Vein - In anterior interventricular groove
Small Cardiac Vein - Right Sided
Posterior vein is the :
Middle Cardiac Vein
Left Marginal Vein
Left posterior ventricular vein
Heart B
Label 1 - 16
1. Iliac Crest 2. Iliac Tubercle 3. ASIS
4. Gluteal Fossa 5. Body of Ilium
6. Lunate surface 7. Acetabular Fossa
8. Acetabular Notch 9. Ischial Tuberosity
10. Ischial Body 11. ischial spine
12. AIIS 13. Iliac Fossa 14. Iliac Tuberosity15. PSIS 16. PIIS
Label 17-32
- Arcuate Line
18. Iliopubic eminence 19. Pubic tubercle
20. pubic crest 21. pubic symphysis
22. Inf. Pub. Ramus 23. Ischial Ramus
24. Obturator Crest 25. Lesser Sciat. Notch
26. Greater Sciat. Notch
27. Groove for obturator Externus
28. Post. Gluteal Line 29. Inf. Gluteal Line
30. Ant. Gluteal Line 31. Obturator foramen
32. Obturator groove
Greater Sciatic Foramen
i) Boundaries of greater sciatic foramen
ii) Structures passing through the GSF
i) Anterolateral - Greater Sciatic Notch of ilium
Posteromedial - Sacrotuberous ligament
Inferior- Sacrospinous lig and ischial spine
Superior - Ant. Sacroiliac ligament
ii) Piriformis runs through and ‘divides the GSF’
Total - 7 nerves, 3 Vascular Sets + Piriformis
Above Piriformis
Superior Gluteal Vessels + Nerve
Below Piriformis
Vascular - a) Inf Gluteal Vessels b) Int. Pudendal vessels
Nerves - a) Sciatic Nerve b) Inf. Glut. Nerve
c) Pudendal Nerve d)Post. Fem. Cutaneous Nerve
e) Nerve to obturator Internus
f) Nerve to quadratus femoris
i) Blood supply to the hip joint
ii) Attachment of capsule to the femur
iii) Extracapsular/Intracapsular hip ligaments
i) Principally three arteries:
Medial Circumflex Femoral Artery (largely)
Lateral Circumflex Femoral Artery
Artery to head of femur (branch of obturator artery with minor contribution)
Medial and lat circ branch of profunda femoris artery
ii) Has both ant. and post. femoral attachment
Ant. - Intertrochanteric Line
Post. - More proximal on femoral neck
iii) Iliofemoral Ligament -AIIS ->Intertrochanteric line
Pubofemoral Ligament - Superior pubic rami -> Intertrochanteric Line (triangular shape)
Ischiofemoral Ligament - Body of ischium -> Greater trochanter (Spirals)
Femur Anatomy
Label 1-11
Attachment for:
1. Gluteus Minimus 2. Piriformis 3. gluteus medius
4. Quadratus Femoris 5. Iliopsoas 6. Glut. Max.
7. Vastus Lateralis 8. Vastus Medialis
9. Obtur. Internus + Gemellae
10. Iliofemoral lig. 11. Lig. Teres
Name Muscles:
i) Flexing hip point
ii) Short external rotators
iii) Abducting the hip joint
i) Iliopsoas, Pectineus, Sartorius, Rectus Femoris
ii) Superior to Inferior. Piriformis, Sup. Gemelli, Obt. int. + Ext., Quadr. Fem.
iii) TFL, Glut. Med + Min
Iliopsoas
Origin
Insertion
Innervation
Origin - Iliac Fossa, T12 - L5 vertebrae
Insertion - lesser trochanter
Innervation - Femoral Nere (+L1-L2)
Origin, Insertion + Inneration of
Glut. Med, Min + TFL
Innervated - Superior Gluteal Nerve (L4-S1 Sacral Plexus)
Glut Med + Min -> Glut Fossa of Ilium -> Greater trochanter
TFL -> Iliac Crest -> IT Band
Gluteal Region
Label Muscles 1-8
Origin 9
Fascia 11-12
Ligament 13
Structures 14-16
Label 17-24
1. Glut. Max. 2. Glut Med. 3. Glut. Min.
4. Piriformis 5. External Obliq. 6. Obt. Extern
7. Obt. Int./ Gemellae 8. Levator Ani
9. Hamstring Origin 10. Iliac Crest
11. Gluteal Fascia 12. Lumbar Fascia
13. Sacrotuberous ligament
14. Ischial Tuberosity 15. Greater Trochanter
16. Hip Joint Capsule 17. Sup. Glut. Art.
18. Sup. Glut. Nerve. 19. Inf. Glut. Nerve
20. Inf. Glut. ARt. 21. Post. Cut. Nerve of thigh
22. Sciatic Nerve (L4-S3) 23. Inf. Rect. Nerve
24. Cutaneous branches of lumbar dorsal rami
Sciatic Nerve
i) Roots
ii) Course
iii) Innervates
i) L4-S3
ii) Ventral Rami L4-S3. Leave pelvis through GSF below piriformis. Travels beneath glut max traversing inferiorly between the greater trochanter and ischial tuberosity.
Travels superficially to adductor magnus before enterring poplital fossa.
iii)
Hamstring Muscles
Adductor Magnus (tibial portion)
External Rotators (Gemellae, Obt. Internus, Quad. Femor.)
Then –>
Common Peroneal Nerve : Ant. + Peroneal comparments
Tibial nerve: Deep and Superficial Posterior Compartments
sensation to posterior thigh and lateral leg
Post. Knee.
Label
1. Med. Fem. Condyle 2. lat. Fem. Condyle
3. Fibular Head 4. Med. Meniscus 5. Lat. Meniscus
6. Post. Meniscofem. Lig 7. Post. Cruc. Lig
8. popliteus 9. Lat. Collateral Lig.
10. Prox. Tibiofibular Joint 11. Femur 12. Patella
13. Tibia 14. Fat Pad 15. Quadriceps Tendon
16. patella tendon 17. Suprapatellar bursa
Knee Label 2
1. Lat. Fem. Condyle 2. patella 3. Tib. Tuberosity
4. Quad. Tendon 5. Patel. Tendon
6. Lat. Meniscus 7. Lat. Colat. Lig
8. Bicep Femoris (Reflected inferiorly)
9. Popliteus 10. Lat. Head of gastroc. + plantaris
11. Tibial Nerve 12. Common Peroneal Nerve
13. Med. Fem. Conyle 14. Vastus Medial.
15. Hamstring tendon portion of add. magnus
16. Adductor Tubercle 17. Gracilis 18. Sartorius
19. Semitendinosis 20. Pes Anserina
21. Medial Gastrocnemius 22. Tibia
23. Med. Collat. Lig. 24. Adductor Hiatus
Knee Joint (Left)
Label 1-14
1. Patella Groove 2. Sup. Lat. Fem. Condyle
3. Sup. Med. Fem. Condyle 4. Med. Fem. Condyle
5. Lat. Fem. Condyle 6. Med. Tib. Condyle
7. Lat. Tib. Condyle 8. intercondylar eminence
9. Tib. Spine 10. Intercondylar Notch
11. ACL 12. PCL 13. Lat. Meniscus 14. Med. Meniscus
Where do they attach:
i) ACL
ii) PCL
iii) MCL
iv) LCL
v) Which nerve/artery is commonly injured in knee dislocation?
i) ACL - Lat. Condyle of femur -> Anterior intercondylar area
ii) PCL - Med. Condyle of femur -> Post. intercondylar area
iii) MCL - medial epicondyle of femur -> med tibial condyle
Part of the MCL directly communicates with the medial meniscus
iv) LCL - lateral epicondyle of femur -> fibular head
seperate from lateral meniscus
v) Common peroneal nerve - roughly 15%
Popliteal Artery - roughly 10%
Popliteal Fossa:
i) Boundaries
ii) Contents
iii) Where do the Popliteal LNs drain?
i) Superior
Lateral - Bicep Fem
Medial - Semi memb/tend
Inferior
Med/Lat - Gastrocnemius
Roof - Fascia Lata
Floor - Post knee joint capsule + poplitues musc.
ii) Contents: (superficial to deep)
Nerves (most superficial) - Common peroneal nerve - Medial to bicep fem tendon.
Tibial Nerve - Crosses from lat. side of vessels to medial
Post. Cutaneous nerve of thigh - Medial
Pop. Vein (+lesser saphenous) then Pop. Artery
iii) Popliteal LNs drain the venous distrubiton of SSV
Popliteal Region
1-17
1. Semimembranosis 2. Biceps Fem
3. Semitendinosis 4. adductor magnus
5. plantaris 6. med. Gastroc. head
7. lat. gastroc. head 8. IT Band 9. Adductor Hiatus
10. Pop. Vein 11. Pop. Art. 12. Tib. Nerve
13. Common Peroneal Nerve
14. Med. Head Gastroc. Nerve 15. Sural Nerve
16. Sup. Lat. Genicular Artery
17. inf. lat. Genicular art.
Describe lower limb blood supply
Femoral artery - Continuation of external iliac artery becoming the femoral artery as it passes beneath the inguinal ligament to enter the femoral triangle. Beyond the femoral triangle it descends in the adductor canal.
Profunda femoris artery is a posterolateral branch of the femoral artery. In turn it gives off 3 main branches - Med and lat fem circumflex arteries and then some perforating muscular branches.
Obturator artery - arises from internal iliac artery and enters medial thigh through the obturator foramen. Supplies medial thigh compartment / deep gluteal muscles
Popliteal artery (discussed further below) - gives off 3 medial and 2 lateral genicular arteries
Lower Leg
Superficial femoral artery becomes Popliteal artery as it exits the adductor hiatus and enters popliteal fossa.
Just inferior to the popliteal fossa it bifurcates:
Anterior Tibial Artery - Becomes the dorsalis pedis artery in the foot (passes anteriorly beneath extensor retinaculum)
Tibioperoneal trunk -which then birfucates into the: posterior tibial artery passing posterior to medial malleolus
peroneal artery
The Leg Bones
Structures 1-9
Attachments 10 - 21
1. med. tib. condyle 2. lat. tib. condyle
3. tib. tuberosity 4. Med. surf. tibia
5. fibular neck 6. fib head 7. Tibial Spines
8. Popliteal surface of tibia 9. Soleal line
10. Semimembranosis 11. patella tendon
12. Bicep Fem. 13. Soleus 14. Popliteus
15. Semitendin. 16. Gracil. 17. Sartorius
18. Pes Anserina 19. Med. Colat. Lig
20. Lat. Colat. Lig 21. IT Band
Lower Limb Compartments, blood supples, muscles, nerves
i) Anterior Compartment
Deep peroneal nerve/ Anterior Tibial Artery
Anterior Tibialis, Extensor Hallucis Longus, Extensor Digitorum Longus, Peroneus Tertius
ii) Peroneal Compartment
Superficial peroneal nerve/ Peroneal Artery
Peroneus Longs, Peroneus Brevis
iii) Superficial Posterior Compartment
Tibial Nerve/ Posterior TIbial Artery
Gastrocnemius, Soleus, Plantaris
iv) Deep Posterior Compartment
Tibial nerve/ Posterior Tibial Artery
Tibialis Posterior, Popliteus, Flexor hallucis longus, flexor digitorum longus
Surface markings of foot
Label
1. Lateral Malleolus 2. Medial malleolus
3. Tibialis Ant. 4. Extensor Hallucis Longus
5. Extensor Digitorum Longus
6. Extensor Digitorum Brevis
Structures running
- posterior to medial malleolus
- anterior to medial malleolus
Posterior to med. malleolus:
Ant. -> Post (Tom, Dick + Very Nervous Harry)
Tib. Post
Flexor Digitorum Longus
Post. Tibial Art.
Post. Tibial Vein
Tibial Nerve
Flexor Hallucis Longus Tend.
Anterior to medial malleolus :
Long saphenous vein
Foot - Label
1. Med. Malleolus 2. lat. malleolus 3. Tib. Anterior
4. Extensor hallucis longus 5. Extensor Dig. Long.
6. Extensor Dig. Brev. 7. Peroneus Brev.
8. Peroneus Tertius. 9. Extens. Halluc. Brevis.
Foot skeleton - label bony landpoints 1-25
1. Calcaneus 2. Talar Dome
3. Talar Neck 4. talar head 5. Navicular
6. Cuboid 7. Lateral Cuneiform
8. Intermediate Cuneiform 9. Medial Cuneiform
10. 1st Metatarsal 11. 3rd Metatarsal
12. 5th Metatarsal 13. Distal Phalanx 14. Proximal Phalanx 15. Distal phalanx 16. Middle Phalanx
17. Proximal phalanx 18. 1st metatrsal head
19. 1st metatarsal shaft 20. 1st metatarsal base
21. Ant. Tuberc. Calcaneus 22. Substentaculum Tali
23. Lateral process of calcaneus
24. Medial Tubercle of Talus
25. Lateral Tubercle of Talus
26 - Name the fracture
27-29 - Tendons traversing groove
26. Jone’s Fracture - diaphyseal 5th metatarsal
27 + 28. Flexor Hallucis Longus
29. Peroneus Longus
i) Anatomical Divisions of foot
i) Forefoot - MTs + Phalanges
Midfoot - Cuboid, Navicular + Cuneiform Bones
Hindfoot - Talus + Calcaneus ( True anle joint is between talus and tib/fib. Subtalar Joint between talus + Calcaneus)
Foot Ankle Label
1. Medial Malleolus 2. Calcaenus 3. lateral malleolus
4. Navicular 5. Medial Cuneiform
6. 1st metatarsal 7. talar dome
8. Cuboid 9. 5th metatarsal
10. Achilles Tendon (common tendinous insertion of gastrocnemius, plantaris + soleus)
11. Deltoid ligament 12. Posterior talo-fibular ligm.
13. Calcaneofibular ligament 14. Anterior talo-fibular ligament. 15. Long Plant. Ligament
16. Peroneus Brevis
Structures running posterior to lateral malleolus and where they go in the foot.
Peroneus Brevis - (From fibula) to 5th metatrsal (alongside peroneus tertius)
Peroneus Longus - (More proximally on fibula) to 1st metatarsal
Describle ankle ligmanets
Medially: Deltoid ligament
This spans from the medial malleolus (tibia) to
i) substentaculum tali ii) calcaneonavicular lig.
iii) navicular tuberosity iv) medial talus
Laterally: Three Ligaments
Anterior Talofibular Ligament (Lateral Mal. of fib to ant. talus)
Posterior Talofibular Ligament (Lateral Mal. of fib to
post. talus)
Calcaneofibular ligament (Lateral Mal. to Lat. Calcan.)
Syndesmotic:
Anterior + Posterior Inferior Tibiofibular ligaments
What is the angle between the femoral neck and the femoral shaft
125 degrees
What type of bone is the patella?
The patella is a sesamoid bone
Label A-H
A. Vastus Medialis
B- Sartorius
C- Gracilis
D - Medial Gastroc
E/F - Semintendinosis
G - Rectus Femoris
H - Adductor Magnus (Hamstring Portion)
Attachments of cruciate ligaments
Anterior Cruciate Ligament - Anterior tibia to lateral intercondylar notch of femur
Posterior Cruciate Ligament - Posterior tibita to medial intercondylar notch of femur
Label 1-12
What articulates with 7+8
1. Humerus Head 2. Anatomical Neck
3. Surgical Neck 4. Greater Tub.
5. lesser tub. 6. Bicipital groove
7. Capitulum (radius head) 8. Trochlea (Ulna trochlea fossa) 9. Coronoid Fossa
10. Medial Epicondyle 11. Lateral Epicondyle
12. Olecranon fossa
Rotator Cuff Muscles
Origins, insertions, innervations
Supraspinatous - Supraspinatous fossa - Sup. fac. Greater tuberosity. abducts
Suprascapular Nerve
Infraspinatous - Infraspinatous Fossa - Med. Fac. greater tuberosity. external rotate
Suprascapular nerve
Teres Minor - Lateral border of scapula - Inf. Fac. Greater tuberosity
Axillary Nerve. external rotate
Subscapularis - Subscapular fossa - Lesser Tuberosity
Upper + Lower Subscapular nerves. internal rotate
Muscles at coracoid process
Muscles at intertubercular groove
Muscles at greater tubercle
Muscles at lesser tubercle
Coracoid Process: Three Muscles
- Short head of biceps*
- Corachobrachialis*
- Pectoralis minor*
Interubercular Groove: Three Muscles
- Latissimus Dorsi*
- Pectoralis Major*
- Teres Major*
Greater Tubercle: Three Muscles
- Supraspinatous*
- Infraspinatous*
- Teres Minor*
Lesser Tubercle: One Muscle
Subscapularis
Biceps
Innervation, attachment, insertion
Which head is more lateral mid -humeral shaft
Biceps - Musculocutaneous nerve (Lat. Cord- C5-C6)
Short head: Coracoid Process
Long Head: supra-glenoid tubercle
both insert onto the bicipital tuberosity (radius)
Long Head is situated more laterally mid -humeral shaft. Generall the long head is the more bulky of the two.
Label 1-5
What attaches to 5
1. Subscapularis 2. Supraspinatous
3. Long Head Biceps 4. Short head biceps
5. Coracoid Process
Muscles - Corachobrachialis, short head biceps, pectoralis minor
Ligaments - Corachoclavicular, corachoacromiial, coracohumeral lig., superior transverse scapular lig.
Humerus
What muscles attach to 1-15
10 - What runs here
16. What fracture?
17. Which nerve traverses this structure
1. Supraspinatous 2. Subscapularis
3. Lat. Dorsi 4. Pec. Major 5. Teres Major
6. Coracobrachialis 7. Brachialis
8. Brachioradialis 9. Extensor carp. radi. long.
10. Radial groove (radial nerve)
11. Infraspinatus 12. Teres Minor
13. Triceps (Lat.) 14. Triceps (Med.)
15. Anconeus 16. Supracondylar
17. Medial epicondyle (humerus) - Ulnar nerve
Describe route of radial nerve + innervation
Originates from posterior cord of brachial plexus.
Exits the axilla - through triangular space (Lat - Humerus, Med - Long head triceps, Sup - Teres Major)
Before the elbow it innervates:
Triceps, Brachioradialis, anconeus, Extensor carpi radialis longus
+ 3 sensory branches (posterior cutaneous nerve of arm, forearm + lateral cutaneous nerve of arm)
Then
Travels along the radial groove posteriorly before piercing intermuscular septum to enter cubital fossa at lateral epicondyle dividing into the:
superficial radial nerve (sensory) - runs lateral to radial art. under brachioradialis into the anatomical snuffbox supplying the hand
posterior interosseus nerve (motor) - pierces supinator distal to the radial head and runs in the extensor compartment supplying supinator + extensors
Brachial Plexus - label
1. CCA 2. SCA 3. Axillary art.
4. Brachial Art. 5. Subclavian Vein 6. Axillary Vein
7. lat. cord 8. post. cord 9. med. cord.
10. Thoracoacromial trunk 11. Lat. Thorac. art.
12. Axil. Nerv 13. Musculocut. nerve
14. Radial nerve. 15. Median Nerve
16.Median Nerve 17. Ulnar nerve + medial cut. nerve of forearm
18. Thoracodorsal nerve 19. Long thoracic Nerve
20. Cephalic vein 21. External Jug. Vein
Antecubital Fossa
i) Boundaries
ii) Contents
i) Boundaries:
Med- Pronator Teres
Lat. - Brachioradialis
Sup. - line between epicondyles
ii) Contents:
Median Nerve (just medial to brachial art.)
Brachial Art.
Biceps Brachii Tendon
Deep branch of radial nerve ( becomes post. interos. n.)
Antecubital Fossa
1. Biceps Tendon 2. Brachial Art. 3. Med. Nerve
4. Basilic Vein 5. (medial epicondyle side)
6. (lateral epicondyle side) 7. Median. Cub. Vein
8. Cephalic Vein 9. Rad. Recurrent Vein
10. Med. Cut. Nerve of forearm
11. Ulnar nerve 12. radial nerve 13. Sup. Rad. Nerve
14. Deep Rad. Nerve 15. Post. Interosseus Nerve
16. Lat. Cut. Nerve of forearm 17. Brachioradialis
18. Biceps 19. Pronator Teres
20. Bicipital Aponeurosis
Elbow Joint
1. Humerus 2. Lateral Epicondyle
3. Medial epicondyle 4. Radial Fossa
5. Coronoid Fossa 6. Capitulum 7. Trochela
8. Coronoid Process 9. Radial Neck 10. Radial Head
11. Olecranon 12. Radial Tuberosity
13. Radial Collateral Ligament
14. Ulna Collateral Ligament 15. Annular Ligament
16. Supinator Fossa 17. Lateral Supracondylar Ridge
18. Medial supracondylar ridge
Elbow Joint
Muscles attaching 1-11
1. Brachialis 2. Brachioradialis
3. Extensor Carpi Radialis Longus 4. Pronator Teres
5. Brachialis 6. Flexor Digitorum 7. Pronator Teres
8. Supinator 9. Flexor Digitorum Profundus
10. Biceps 11. Triceps
Forearm (Ant.)
1. Bicep Tendon 2. Brachial art. 3. Median Nerve
4. Median Cubitan Vein 5. Cephalic Vein
6. Bicipital aponeurosis 7. Ulnar Art.
8. Recurrent Radial Art. 9. Ant. Interosseus Nerve.
10. Common Interosseus Art. 11. Radial ARt.
12. Superficial Palmar Art. (Radial Art.) 13. Ulnar art.
14. Superficial rad. nerve ( Dorsum of hand + anatomical snuffbox) 15. Brachioradialis
16. Pronator Teres 17. Flexor Carpi Radialis
18. Flex. Dig. Profondus 19. Palmaris longus
20. Flexor Carpi Ulnaris
Forearm (post.)
1. Brachioradialis 2. Extensor carpi radialis long.
3. Extensor carpi radialis brev. 4. Extensor digitorum
5. Ulna Head 6. Extensor Carpi Ulnaris
7. Extensor digiti minimi 8. Abductor pollic. long
9. Extensor pollic. long. 10. Extensor pollic. brev.
11. Extensor carpi radialis longus
12. Extensor carpi radialis brevis
Extensor aspect Right distal forearm
1. Extensor digitorum 2. Extensor digiti minimi
3. Extensor carpi ulnaris 4. extensor pollicis longus
5. extensor carpi radialis brevis
6. Abductor Pollicis longus
7/8. Extensor Pollicis Brevis 9. Extensor pollicis Longus 10. Extensor indices 11. Extensor Retinaculum
12. Radial head 13, Interossues Membrane 14. Anterior Interosseus Artery
15. Radial nerve
Flexor Aspect Forearm
1. Biceps Tendon 2. Brachial Art. 3. Median Nerve
4. Median cubital vein 5. Bicipital Aponeurosis
6. Radial Nerve 7 + 8. Cephalic Vein
9. Radial Artery 10. Ulnar ARtery 11. Ulnar nerve
12. Anterior interosseus nerve (median nerve)
13. Anterior interosseus artery 14. Ulnar artery
15. Brachoradialis 16. Pronator Teres
17. Flexor Carpi Radialis 18. Flexor Carpi Ulnaris
19. Palmaris Longus 20. Pronator Quadratus
21. Flexor Digitorum Superficialis Tendon
22. Palmaris Longus Tendon
Muscles attaching to the medial epicondyle
Pronator Teres
Flexor Carpi Radialis
Palmaris Longus
Flexor Digitorum Superficialis
Flexor Carpi Ulnaris
Deep flexors of the forearm + nerve supply
These arise form the volar surface of ulna +radius:
Flexor Pollicis Longus
Flexor Digitorum Profundus
Pronator Quadratus
ALL of the flexors are supplied by the Median Nerve
Except
Ulnar half of Flexor Digitorum Profundus + Flexor Carpi Ulnaris - Ulnar Nerve
Course of terminal brachial artery branches
Bifurcates at antecubital fossa into :
i) Radial Artery - Continues laterally and anteriorly. Winds laterally around the wrist passing through the anatomical snuffbox.
ii) Ulnar ARtery - Runs deep at its origin on top of brachialis and flexor digitorum profundus. Relationship to medial nerve is important as it begins medially before crossing it to run laterally. Enters the wrist underneath transverse carpal ligament on radial side of psiform bone within guyon’s canal
The Wrist
1. Radial Styloid 2. Lister’s Tubercle
3. Surface for scaphoid 4. Surface for lunate
5. Ulnar styloid 6. Hook of hamate 7. Pisiform
8. Trapezum Ride 9. Scaphoid Tubercle
10. Flexor Retinaculum 11. APB Tendon
12. EPB Tendon 13. ECRL Tendon 14. ECRB Tendon
15. EPL Tendon 16. ED Tendon 17. EI Tendon
18. EDM Tendon 19. ECU Tendon
20. Triangular Fibrocartilage
Median Nerve Exam?
Look - Thenar wasting, ulnar deviation
Sensation - Thenar eminence (superficial median nerve) Volar aspect of index finger (median nerve)
motor -
Okay sign - FPL/FDP
Palms on table and abduct thumb - APB
Hold the middle phalanx and flex finger tip - FDP
Hold all other fingers in extension and ask them to flex one - FDS
Pronate in elbow extension - Pronator Teres
Special Tests:
Do a button - FDP/FPL
Tinel’s Sign - Tap
Phalen’s sign - flex for 60 seconds
Compression test - symptoms
Median Nerve:
Hand:
Forearm:
Nerve Roots:
Course:
Hand: Lateral Lumbricals, Opponens Pollicis
Abductor pollicis Bevis, Flexor Pollicis Brevis
Forearm:
Median Nerve Proper: Flexor Carpi Radialis, Flexor digitorum superficialis + palmaris longus
Anterior interosseus branch: FPL, Pronator Quadratus, Radial half of flexor digitorum profundus
Nerve Roots:
C6-T1
Course:
Originates from Lateral and Medial Cord.
Travels lateral to brachial artery in upper arm and then crosses to the medial side in the antecubital fossa.
Leaves the antecubital fossa between two heads of pronator teres giving off the
Anterior interosseus nerve (runs on the AIM between the FPL and FDL)
median nerve proper (continues more superficially to pass beneath the flexor retinaculum giving off palmar cutaneous muscle prior to passing through the carpal tunnel)
Aorta:
What lies anterior to the aorta at L1?
L1 - SMA + Neck of pancreas
Branches of the aorta
Anterior:
T12 - Coeliac Axis (L gastric, Common Hepatic, Splenic)
L1 - SMA (Inf. Pancreatoduodenal, Jej + Ileal, Ileocolic, Right Colic, Middle Colic)
L3 - IMA ( Left Colic, Sigmoid, Sup. Rectal)
Posteriolateral:
T12- Inferior Phrenic
L1 - Suprarenal
L1-L2 - Renal Arteries
L2 - Gonadal Arteries
L1-L4 Four paired Lumbar arteries
Structures in the transpyloric plane
Midline - Post(Ant).
L1 vertebra, Aorta, SMA, Neck of Pancreas, SMV , Pylorus
Lateral - Kidney hila, renal veins, Spleen hilum, Duodenum 2nd part, Portal vein formation (SMV + Splenic Vein meet), DJ Fexure, GB fundus, 9th costal cartilage
Epiploic foramen of winslow
Communication between the greater and lesser sac of the peritoneal cavity.
Lesser Sac- Posterior to stomach medially/ posterior to greater sac laterally
Ant - Hepatoduodenal ligament of the lesser omentum (CBD, Common Hepatic Artery, Hepatic Portal Vein)
Post - IVC
Sup - Caudate lobe liver
Inf - 1st part duodenum
Spleen Functions
Structures that can be damaged in spleenctomy
Ligaments of the spleen
Functions: FISH
Filtration of encapsulated organisms
Immunological function
Storage of platelets
haematopoeisis in fetus
Potential to be damaged:
L Kidney, Splenic flexure, Stomach, Tail of pancreas, diaphragm
Ligaments
Gastrosplenic Ligament (greater curvature) - contain short gastric and left gastroepiploeic vessels
Lienorenal Ligament (attaches to the left kidney) - contains splenic vessels and tail of pancreas
i) Define: portosystemic anastamosis
ii) Sites of portosystemic anastamosis
i) Reconnection of the portal venous system with the systemic venous system.
ii) Oesphageal - Left Gastric/ Portal –> Azygous (system)
Rectal - Sup Rectal vein (port.) –> Mid/Inf Rect Veins (system)
Retroperitoneal
Umbilical
Hepatic (bare area)
What structure lies at the level of the 12th rib posteriorly?
Which parts of the duodenum are retroperitoneal?
Which abdominal organs are intraperitoneal?
12th rib posteriorly - Superior Renal Pole
Retroperitoneal parts of duodenum - 2nd, 3rd and 4th
Intraperitoneal Organs - Stomach, 1st part of duodenum, Colon (caecum, transverse, sigmoid), Tail of pancreas, Liver, Uterus and ovaries
Differentiating between the jejenum and ileum?
Jejunum is (compared with ileum) -
Larger
Thicker
More Vascular
Darker Red
Longer vasa recta
Fewer arcades
Differentiating between small bowel and large bowel:
i) Radiologically
ii) Intraoperatively
i) Radiologically -
Haustrae (large bowel - traverse 1/3 width) and Valvulae Conniventes (Small bowl - entire width)
Small bowel is more central
Large bowel is more circumferential
ii) In addition - operatively:
Large bowel has appendices epiploicae and taenia coli
Pancreas:
i) Parts
ii) Function
iii) Blood Supply
i) Parts: Head, Neck, Uncinate, Body, Tail
ii) Function:
Endocrine - Glucagon (alpha cells), Insulin (beta cells), Somatostatin (Delta Cells)
Exocrine - Lipases, Amylase
iii) Blood Supply:
Superior Pancretoduodenal Artery (gastroduodenal)
Inferior Pancreatoduodenal Artery (SMA)
Splenic Artery Branches
Blood Supply to the stomach:
Lesser Curve
Greater Curve
Lesser Curve - Right and Left Gastric Arteries
Greater Curve - Left (Splenic Art.) and Right Gastroeipoloic Arteries (Gastroduodenal Art.)- both also supply the greater omentum
Kidneys:
i) Anatomical Position
ii) Layers of adrenal Gland
i)
Pelvis - L1
Between T12-L3 vertebrae
ii) Relations:
Both:
Sup - Diaphragm,
Inf - Quadratus Lumborum
Lat - Transversus Abdominus
Med- Psoas major
Left Ant - Adrenal, spleen, stomach, tail of panc, small intest., colon
Right Ant- Adrenal, liver, colon, duodenum, small intestine
ii) Adrenal Layers:
Cortical Layers
Glomerulosa - Mineralocorticoid
Fasciculata - Glucocorticoid
Reticularis - Sex Hormone
Medulla - Catecholomines
Topography of Peroneus Longus, Brevis + Tertius
Peroneus longus - head of fibula -> Medial cuneiform and base of 1st metatarsal
Peroneus Brevis - lower 2/3 of lat fib -> base of 5th metatarsal
peroneus tertius - lower 1/3rd fib and IO membrane -> base of 5th metatarsal
Where do you test the following:
S1
L4
Deep Peroneal Nerve
Superficial peroneal Nerve
Sural Nerve
Tibial Nerve
Saphenous Nerve
S1- Lateral foot
L4 - Medial malleolus
Deep Peroneal Nerve - First web space
Superficial peroneal Nerve - Dorsum of foot (not first web space)
Sural nerve - Lateral malleolus
Tibial nerve - Posterior Sole of foot
Saphenous nerve - Medial Aspect of foot
i) Vessels + nerve beneath Extensor Hallucis Longus?
ii) Muscles involved in foot dorsiflexion?
iii) Muscles involved in foot plantarflexion?
iv) What do TA and TP combined cause to happen?
v) What do PL and PB combined cause to happen?
vi) Through what joint does ankle flexion/extension occur?
vii) Through what joint does ankle inversion/eversion occur?
i) Anterior Tibial Artery and Vein
Deep Peroneal Nerve
ii) AT, EHL, EDL, PT
iii) Gastroc, Soleus, Plantaris (Superficial)
FHL, FDL, Pop, TP
iv) Foot inversion
v) Foot eversion / Dorsiflexion
vi) Flexion extension through - Talar-fibula/tibia joint
vi) inversion/eversion through - Subtalar joint
i) Where is the true ankle joint?
ii) Where is the subtalar joint?
i) True ankle - synovial joint between tib/fib + talus
ii) Subtalar joint - Between the talus and calcaneous
Gluteal tuberosity (Gluteus maximus attachment)
Topography/action of :
Anterior Tibialis
Extensor hallucis Longus
Which nerves/ arteries/ veins are in which leg compartment?
Anterior Tibialis - Lateral tibial condyle –> Medial cuneiform and first metatrsal (dorsiflex/invert)
Extensor Hallucis Longus - Anterior fib/ IO membrane–> Distal phalanx of hallux (dorsiflex foot/hallucis + invert foot)
Anterior Compartment - ATA, ATV, Deep peroneal n.
Lateral Compartment - Superficial peroneal nerve
Deep posterior compartment - PTA, PTV, Tibial Nerve, Peroneal Artery
Leg muscles attaching to the medial cuneiform?
Attaching to the medial cuneiform - PL, TA, TP
nerve supplying sensation to the :
Medial Leg
Dorsum of Foot
First web space
Medial leg - Saphenous
Dorsum of foot - Superficial peroneal Nerve
First web space - Deep peroneal nerve
Label and describe
Pop Art. –> Divides into AT and TP Trunk
AT travels along the IO membrane in the anterior compartment becoming the DPA when it crosses between med/lat malleoli
TP Trunk divides 2.5cm after the initial bifurcation into the PTA and the PA.
PTA - in posterior compartment runs behind medial malleolus
PA - in posterior compartment between Tib. Post + FHL
i) Gross anatomical route of greater saphenous vein
i) “” of the lesser saphenous vein
i) Originates from dorsal venous arch of foot
Passes anterior to medial malleolus
Posterior to medial epicondyle of femur
Enters the femoral triangle and joins the femoral vein at the SFJ
ii) Originates from doral venous arch of foot.
Posterior to lateral malleolus
Runs posteriorly with the sural nerve.
Joins popliteal vein in popliteal fossa
Route/Function of vas deferens
From the epididymis through the inguinal canal to
Pelvic side wall to
Ejaculatory Ducts
It functions to transport sperm from the testes to the urethra
What is the structure arrowed?
What is function?
Seminal Vesicle
Outpouching of the vas deferens ampulla responsible for producing a fair volume of seminal fluid
Bladder:
i) Angle of ureteric entry
ii) Relations
iii) What is the pouch of douglas?
iv) Arterial Supply / Venous Drainage
v) Muscular ‘arrangement’ of the baldder?
vi) Inneration
i) Ureter enters bladder obliquely
ii) Relations:
Ant - Pubic Symphysis
Post - Recto-vesic pouch/denonvillier’s Fascia/ Rectum/ prostate - Male, Vesico-uterine pouch/Vagina - Female
iii) Pouch of douglas - Rectouterine pouch
iv) Arterial Supply - (Internal Iliac artery via:)
Sup. Vesicular Art
Mid. Vesicular Art
Inf. Vesicular Art.
(Prostatovesical in men) Vesical Venous Plexus –> Internal Iliac veins
v) Detrussor muscle is arranged into :
Longitudinal, circular + spiral bundles
vi) Innervation:
PNS (encourages micturition) - Pelvic Splanchnic Nerves + Inf. Hypogastric Plexus (S2-S4)
SNS (prevents micturition) - Hypogastric plexus
Pudendal Nerve (s2-s4) - External Urethral Sphincter
Ureters:
i) Arterial supply
ii) Normal ureteric narrowings + significance
iii) How is pain from the ureter transmitted?
i) Divided into 3:
Upper 1/3rd - Renal art., Aortic branches, Gonadal Branches
Middle 1/3rd - Common iliac, Gonadal
Lower 1/3rd - Common Iliac/ Internal Iliac (Partic. Superior vesicular artery +uterine art.)
ii) Significance - Stones most often get stuck here
VUJ, As they traverse the pelvic rim, PUJ
iii) Upper + middle - T11- L2
Distal - Genitofemoral + Ilioinguinal nerves
Where can the different brachial plexus components be found?
Roots- Between anterior and middle scalene
Trunks - Base of posterior neck triangle
Divisions - Posterior to middle third clavicle
Cords - Surround the 2nd part axillary artery
Branches - Around the 3rd part axillary artery
Long thoracic nerve:
i) Roots
ii) Supplies
Roots of the:
iii) Medial cutaneous nerve of the forearm
iv) Medial cutaneous nerve of the arm
v) Thoracodrosal Nerve
vi) Medial Pectoral Nerve
vii) Lateral pectoral Nerve
i) Roots - C5-7
ii )Serratus Anterior
iii) C8
iv) T1
v) C6-8 from posterior cord (Latissimus Dorsi)
vi) C8-T1 from medial cord (Pec Maj + Min)
vii) C5 - C7 from lateral cord (Pec Maj )
Klumpke’s Palsy
i) Mechanism of cause
ii) Features
Erb’s Palsy
KP
i) Abduction / tractional injury
ii) Lower roots effected so :
Intrinsic handle muscles are dennervated
Unopposed action of flexors/extensors of forearm ->
Claw hand (flexed IP joints , extended MCP joints)
EP
iii) Donward force from humeral head / shoulder.
iv) Waiter’s tip-
Upper nerve roots effected (C5-C6):
Loss of - Shoulder abduction, External rotation, Elbow flexion, supination
Producing - Adducted, internal rotated shoulder.
Extended and pronated forearm
Ulnar nerve compression at wrist - features
More or less pronounced compared to more proximal lesion?
Senosry - medial 1.5 fingers
Motor - intrinsic muscle weakness.
Manifests as clawing of 4th and 5th digits
The clawing is more pronounced at this level as FDP is spared.
Flexor Retinaculum -
i) attachment points
ii) Contents of carpal tunneL)
iii) what supplies senation to thenar eminence
i)
Attaches proximally - Scaphoid (laterally) Psiform (medially)
Distally - Trapezoid (laterally) Hamate (medially)
ii) 1 neve + 10 tendons
Median nerve
4x FDS, 4x FDP, 1 x FPL, 1 x FCR
iii) Thenar eminence sensation supplied by - Palmar cutaneous nerve which is given off before the tunnel
10 non terminal branches of brachial plexus
Roots, Where they come from, What they innervate
Long Thoracic Nerve - C5-C7 Roots. Ser. Ant.
Dorsal Scapular Nerve- C5 Root. Rhomb/ Lev. Scap.
Nerve to Subclavius - C5-C6. Roots. Subclavius
Suprascapular Nerve - C5-C6. Sup. Trunk. Supraspin/Infraspin.
Upper Subscapular Nerve - C5/C6. Post. Cord. Subscapular.
Lower Susbcapular Nerve- C5/ C6. Post. Cord. Subscapular. + Teres Major
Medial cutaneous nerve of forearm- C8. Medial Cord.
Medial cutaneous nerve of arm - T1. Medial Cord.
Medial Pectoral nerve - C8-T1. Medial Cord. Pec Maj+ Min
Lateral Pectoral Nerve - C5-C7. lat. Cord. Pec Maj.
Thoracodorsal nerve - C5-C7. Post. Cord. Latisimmus Dorsi
Superior Limit of the lung pleura?
innervation of the parietal pleura
Innervation of the visceral pleura
Pleura Projects 2.5cm above the middle of the clavicle
Parietal Pleura is innervated by intercostal nerves/ phrenic nerve
Visceral pleura is innervated by the pulmonary plexus
What features does a typical rib comprise of?
What makes certain ribs different?
2 x demifacet - Articulates with vertebra above and below
Tubercle - Articulates with transverse process of vertebra
Subcostal groove - Containing intercostal bundle (SUperiorly - vein, artery, nerve - inferiorly)
Atypical Ribs;
1. Has a single facet and an extra tubercle (Scalene tubercle)
10-12. Have a single facet (articulate with corresponding vertebra alone)
11-12. Have no tubercle
The breast
i) Extent
ii) Vasculature
iii) Lymphatic Drainage
i) Extends from the sternal edge to mid-axillary line from T2-T6
ii) Mainly lateral thoracic artery. Also - Internal thoracic artery, posterior intercostals + thoracoacromial artery
iii) APICAL - Anterior/pectoral nodes, Poterior/subscapular, infraclavicular, central, apical, lateral/brachial
Medially - internal thoracic lymph nodes
Superficially - Contralateral breast + abdominal wall
Superior Mesenteric Artery:
i) Arises from?
ii) Immediately behind?
iii) relation to duodenum?
i) arises from L1 abdominal aorta
ii) immediately behind pancreatic body
iii) Passes anteriot ti 3rd part duodenum and uncinate process of pancreas.
Layers of the abdomen at the level of appendix
Skin
Camper’s Fascia
Scarpa’s Fascia
External Oblique Aponeurosis
Internal Oblique Muscle
Transversus Abdominis
Transversalis Fascia
Extraperitoneal Fat
Peritoneum
Appendix:
i) Positions
ii) how to identify at surgery
i) Retrocaecal, Pelvic, Subcaecal, Postileal, Preileal
ii) Three taenia coli converge at the caecum and form longitudinal muscle layer. Where they converge you can find the appendix
Rectum:
i) Vasculature
ii) Innervation
iii) ?Position
iv) Most common sites of colonic cancer?
i) SMA - Inferior Mesenteric
MMA - Internal Iliac
IMA - Internal pudendal artery
ii) Innervation:
Parasympathetic - S2-S4 (nervi erigentes). Fullness sensation + relaxation of IAS
Sympathetic - Superior hypogastric plexus + lumbar splanchnic nerves. Pain + contraction of IAS
iii) Retroperitoneal
1st third - Covered by peritoneum anteriorly/laterally
2nd third - Covered by peritoneum laterlly
Final third - Extraperitoneal
iv) Sigmoid then rectal
Differentiating between occulomotor nerve palsy and horner’s syndrome?
CN III Palsy - Pupil down and out
- Pupil dilated (Unopposed sympathetic activity as CNIII carries PNS fibers to the sphincter pupillae).
- Ptosis (Dual innervation CNIII and sympathetic)
Horner’s Syndrome -
- Ptosis
- Pupil Constricted (loss of sympathetic nerve) (meosis)
- Enopthalmos (and anhydrosis)
Extraocular Muscle Innervation
CN III - Sup. Rectus, Med. Rectus. Inf. Rectus, Inferior Oblique, Levator Palpebrae Superioris
CNIV - Superior Oblique
CN VI - Lateral Rectus
Components of:
i) Medial Longitudinal Arch
ii) Lateral Longitudinal Arch
iii) Transverse Arch
i) Medial Longitudinal Arch
Bones: Calcaneum, Talus, Navicular, 3 cuneiforms, medial 3 metatrsals
Ligaments - Interosseus/ spring
Muscles - FHL, FDL, FDB, TA, TP
ii) Lateral Longitudinal Arch
Bones: Calcaneum, Cuboid, lateral 2 metatarsals
Ligaments: Long and short plantar ligaments
Muscles; Peroneus Longus, FDL, FDB
iii) Transverse Arch
Bones - Base of all metatarsals
Ligaments - Interosseus
Muscles - Peroneus Longus,
Describe the four muscle layers of the foot
Deep:
- Interossei, PL + TP tendons
- FHB, AH, FDMinimi
- Quadratus PLantae, lumbricals. FHL, FDL tendons
- Abductor Hallucis, Abductor Digiti Minimi, FDB
Most superficial
What is the arrowed structure?
Pronator Teres
i) Flexors of the elbow joint
ii) Boundaries of antecubital fossa
iii) Contents of antecubital fossa
i) 3Bs Biceps, Brachialis, Brachioradialis
ii) Lateral - Brachioradialis
Medial- Pronator Teres
Superior- Imaginary line through the humeral epicondyles
Superficial - Bicipital Aponeurosis
Deep - Brachialis/Supinator
iii) Antecubital fossa -
(Medial to biceps tendon) - brachial art., median nerve, basilic vein. Medial cubitan vein.
Brach Art. -> Radial + Ulna art.
Compartments of the
What is in the:
i) Anterior Superficial Forearm Compartment
ii) Anterior Deep Forerarm Compartment
iii) Posterior Superficial Forearm Compartment
iv) Posterior Deep Forearm Compartment
i) Anterior Superficial Forearm
Pronator Teres, FCR, FDS, PL, FCU
ii) Anterior Deep Forearm
FPL, FDP, Pronator Quadratus
iii) Posterior Superficial Forearm
Brachoradialis, ECRLong, ECRBrev, EDigit, EDMinim, ECUln, Anconeus
iv) Posterior Deep Forearm
Supinator, EPolB, Ext.Ind., AbdPolL, EPolL
Ulnar Nerve Course
Originates from the medial cord of the brachial plexus.
- Travels post. to medial epicondyle of humerus
- Passes between two heads of FCU to enter anterior compartment of the forearm.
- Anters the the hand alongside Ulnar Art. Through Guyon’s Canal
Compare FDP to FDS
FDP attached to distal phalanges
FDS attached to middle phalanges (splits to allow FDP tendon to pass through)
i) What is the conjoint tendon?
ii) Fibre arrangement of the external oblique and internal oblique (Innervation)
iii) What is the sensory innervation of the teste (dermatome)
i) Thickening of the transversus abdominus as it attaches to the crest of the pubis.
ii) External Oblique - Inferiorly + Anteriorly (hands in pockets). Lower 6 intercostal nerves + Subcostal nerve
Internal Oblique - Inferiorly + Posteriorly ( hands in contralateral pocket). lower intercostal, iliohypogastric, ilioinguinal
iii) T10. Therefore pathology from ureters (also T10) Can radiate to testes. Furthermore testes pathology can radiate to umbilicus
Which structures are enclosed in the femoral sheath?
Femoral Artery + Vein (Not the femoral nerve)
Hunter’s Canal:
i) Borders
ii) Contents
iii) Where is the adductor hiatus?
i)
anterolaterally - Vastus medialis
anteromedially - sarotorius
posteriorly - adductor longus + magnus
ii) SFA, Femoral Vein, Saphenous Nerve, Nerve to vastus medialis
iii) 2/3 along an imaginary line between ASIS and Adductor Tubercel
Boundaries of the carpal tunnel:
i) name them
ii) surface marking of flexor retinaculum
iii) Contents
i) Carpal bones form the floor
Flexor retinaculum form the roof
ii) The distal wrist crease is the surface marking for the proximal flexor retinaculum
iii) 10 Tendons - 4 FDP 4 FDS 1 FPL 1 FCR
Median Nerve
Boundaries of the anatomical snuffbox:
i) Name them
ii) Contents
iii) Blood supply to the scaphoid bone
i)
Lateral(radial) - Abductor Pollicis Longus/ Extensor Pollicis Brevis
Medial (Ulna) - Extensor Pollicis Longus
Floor - Scaphoid Bone /Trapezium / Base of 1st Metacarpal/ Radial Styloid Process
ii) Contents - Radial Art., Radial N., Cephalic Vein
iii) Predominantly from the dorsal/distal ridge via branch of the radial art. The rest of the bone is supplied by retrograde flow
Hand Muscle Innervation:
I) What does the median nerve innervate?
ii) Discriminatory movements for ulnar nerve function and median nerve function?
iii) What do lumbricals do?
iv) What do interosseis do?
v) What prevents bow stringing of the flexor digitorum tendons?
i) Median Nerve in the hand innervates:
Lateral Lumbricals
Opponens Pollicis
Abductor Pollicis Brevis
Flexor Pollicis Brevis
ii)
Ulnar Nerve - Finger Abduction (resisted)
Median Nerve - Thumb Opposition (resisted)
iii) Lumbricals - Flex MCP and Extend IPs
iv) palmar interossei (4) - Adduct digits
dorsal interossei (5) - abduct digits
v) Bowstringing is prevent through a series of ligamentous pulleys:
Flexor Retinaculum
Cruciate and annular ligaments
Describe the compartments of the extensor retinaculum of the wrist
Principally there are 6 compartments:(rad to uln)
- Extensor Pollicis Brevis + Abductor Pol. Long
- ECR L+ B
- Extensor Pollicis Longus
- Extensor Indicis Proprious, Extensor Digitorum Communis
- Extensor Digiti Minimi
- Extenor Carpi Ulnaris
What parts of the heart form the various anatomical borders?
Apex - Left Ventricle
Right - Right Atrium
Left - Left Ventricle
Inferior - Right + Left Ventricle
Front - Right Ventricle
Back - Left Atrium
Describe Pericardial Layers
Three Layers:
Outer Fibrous Pericardium - Attaches to central tendon of diaphragm + great vessels
Inner Serous Pericardium is divided into:
- *Parietal** Serous
- *Visceral** Serous
Cardiac Arteries:
i) LCA / RCA run in the?
ii) Left Anterior Descending also known as the ? runs where?
iii) What is the name of the artery which is a continuation of LAD
iv) From where do the LCA / RCA originate?
i) Atrioventricular Sulcus
ii) Anterior Interventricular Artery runs in the anterior interventricular groove
iii) After giving off the LAD the LCA continues as the L Circumflex Artery
iv) LCA - L Posterior Aortic Sinus (R Post. has no artery originating from it)
RCA - Anterior Aortic Sinus
Sinoatrial Node:
i) Where is it?
ii) Blood Supply?
i) It is on the crista terminalis of the right atrium
ii) Bimodal population distribution.
60% - RCA
40% - LCA
Describe venous drainage of heart
Coronary Sinus is formed from the great cardiac vein + Left Marginal vein over the left ventricle.
Coronary Sinus continues on receiving tributaries (posterior vein of LV, middle cardiac vein, small cardiac vein) and eventually drains into the right atrium between the tricuspid valve and IVC.
Anterior Cardiac Veins drain directly into the right atrium
Muscles attaching to the treater tuberosity of the humerus?
What does the radial nerve run inbetween?
What lies in the intertubercular groove of the humerus?
Origin of biceps long head? Its attachment?
Origin of coracobrachialis? What else comes from here?
Muscles attaching to the greater tuberosity
- Supraspinatous
- Infraspinatous
- Teres Minor
Radial Nerve runs in the spiral groove in between the medial and lateral heads of the triceps
The biceps long head
- lies in the intertubercular groove of the humerus.
- originates from the supraglenopid tubercle
- attaches (alongside the short head biceps in a combined tendon) at the radial tuberosity (of the radius) + the bicipital aponeurosis
Describe relativity of the pectoralis major, teres major and latissimus dorsi attachments on the humerus:
- Pec major attaches laterally on the intertubercular groove.
- Latissimus Dorsi in the middle
- Teres Major medially to latisimmius dorsi
Coracoiod Process Origin:
- Short Head Biceps Brachii
- Croacobrachialis
Attachment points of the ACL
Medial surface of intercondylar area of the tibia –>
Lateral femoral condyle
Runs in a posterolateral direction from the intercondylar area of the tibia
Arterial Supply to the knee?
6 Arteries
Superior - Medial and lateral genicular arteries
Inferior - Medial and lateral genicular arteries
Descending Genicular Arteries
Recurrent Anterior Tibial Arteries
What does vastus medialis do that is different to the other quadriceps muscles?
Stabilises the patellar and knee joint in gait.
All quadriceps muscles:
Flex the hip joint
Extend the knee joint
What do the posterior divisions of L2 - 4 colaesce to form?
Obturator Nerve (Posterior to L2-L4)
Femoral Nerve ( Anterior to L2-L4)
Key differencs between the semitendinosis and the semimemranosis?
Origin - Ischial Tuberosity
Semitendinosis -
Large tendinous insertion
Semimmebranosis -
Most medial hamstring muscle
Membrane like insertion forming an aponeurosis
What are the surface markings:
i) of the liver?
ii) of the gallbladder?
i) The Liver
Superior Right - T4 Costal Cartilage
Superior Left - Mid Clavicular line, T5 Costal cartilage
Inferior - T10 Costal Cartilage, Mid Axillary Line
ii) The Gallbladder
- In the Transpyloric plane
- In between the 9th costal cartilage and the lateral border of rectus muscle
i) Borders of Calot’s Triangle?
Ii )Contents ?
iii) Define Courvosier’s Law
iv) What are kehr’s and boas sign
i) Superior - Inferior liver edge
Medially - Common hepatic Duct
Laterally - Cystic Duct
ii) Contents - Cystic Artery + LN of Lund
iii) Courvosier’s Law - When there is obstructive jaundice and a palpable gallbladder, gallstones are not the cause
iv ) Referred Gallbladder Pain :
Kehr’s - Right shoulder Tip
Boas’ Sign - Scapula
under surface of the liver
1. Right Lobe 2. Left Lobe 3. Quadrate lobe
4. Round ligament of liver
5. Falciform ligament of liver 6. Caudate Lobe
7. IVC 8. CBD 9. Hep. A 10. Portal Vein
11. Cystic Duct 12. Hepatic Duct 13. Gallbladder
Surface Anatomy of the lungs and pleura
i) Surface marking for oblique fissure
ii) Surface marking for horizontal fissure
Level of:
iii) Suprasternal notch
iv) Angle of louis
v) Xiphisternum
Pleura
Superiorly - 2.5 cm above the mid point of the medial clavicle —> Coming down the R+L pleura meet in the midline at the 2nd rib
Parasternally - Right goes down to the 6th rib. Left goes down to the 4th rib (space for the heart).
Going inferiorly -
8th - Mid clavicular line
10th - Mid axillary line
12th - posterior chest
(subtract two from each of these to get the corresponding lung level)
i) Oblique fissure - From T3 vertebra to 6th rib anteriorly
ii) Horizontal fisure (R Only) - 4th costal cartilage to fifth rib in mid axillary line
iii) T2 iv) T4/T5 v) T9
Describe the bronchopulmonary arrangements of respective lungs:
Bronchopulmonary segment: Bronchus, Artery, vein and lymphatics
Right:
10 Bronchopulmonary segments:
Upper Lobe - 3
Middle Lobe - 2
Lower lobe - 5
Left:
9/10 Bronchopulmonary segments
Upper Lobe - 4/5
Lower lobe - 5
Which Structures are present in the lung hilum?
5:
Primary Bronchus
Pulmonary Artery / Vein
Bronchial Artery / Vein
Lymph Nodes
Autonomic Nerves
i) Which layers make up the deep cervical fascia?
ii) Contents of each of these fascia
i) Carotid Sheath, Prevertebral, Pretracheal, Investing layer of deep cervical fascia
ii) Carotid Sheath - CCA, IJV, CN X, Lymph Nodes (in the wall of the sheath is ansa cervicalis)
Prevertebral - Vertebral Column, Deep back muscles, prevertebral msucles (Levator scapulae, Splenius Capitis), scalene muscles, and subclavian artery + brachial plexus in lower neck region
Pretracheal - Thyroid gland, Oesophagus, Trachea, infrahyoid muscles
Investing Layer - Surrounds all of the deep cervical fascial compartments
Where does CN XI cross the Posterior Triangle?
1/3 of the way down SCM –> 1/3 of the way up Trapezius
Oesophagus:
i) Blood Supply/Lymphatic
ii) Causes of physiological narrowings
iii) Origin of oesophageus
iv) Smooth/ Skeletal muscle in the oesophagus
i)
1st Third- Inferior Thyroid Artery
Deep Cervical LNs
2nd Third - Aorta
Para Aortic/ Pre arotic
3rd Third - Left Gastric Artery/ Inferior Phrenic
Coeilac nodes
ii)
- *A** rch of aorta
- *B** ronchus (Left)
- *C** Left Atrium
- *D** iaphragm
However the most norrow part is at the cricopharyngeus sphincter
iii) Originates at C6 level at the cricoid cartilage
iv) Upper third has skeletal muscle under voluntary control to assist swallowing
Describe the Lower Oesophageal Sphincter
A functional Sphincter
- The high pressure zone is maintained by several factors including:
i) Acute angle of entry through diaphragm (Angle of His)
ii) Phreno-oesophageal ligamnet encircling the GOJ
iii) Mucosal folds found at the GOJ
Types of dipahragmatic hernia
i) Hiatus (Sliding or rolling
ii) Bogdalek
iii) Morgagni
iv) Tramatic/ Iatrogenic
Define : Metaplasia
Reversible Replacement of one differentiated cell type with another differentiated cell type.
Retroperitoneal vasculature:
i) Which level do they enter the IVC?
ii) Anterior or Posterior to Renal arteries at hilum?
iii) Which vessels cross the ureter?
iv) Where does the IVC originate and what lies anterior to it at this point?
v) Aorta becomes anterior or posterior in relation to the IVC distally?
i) L1
ii) Anterior to the renal arteries. The most posterior structure at the hilum are the ureters
iii) Gonadal Art+ Vein
Left ureter- Left Colic
Right Ureter- Right Colic + Ileocolic
Uterine Art.
iv) Originates at L5 (Joining of CIVs) and is crossed by the right CIA
v) Proximally - the aorta is posterior and on the left of the IVC.
Distally - distal aorta is anterior to and on the left of the IVC
Retroperitoneal Organs
Kidneys/ Adrenals
Ureters
Bladder
Pancreas (not tip or tail)
Duodenum (not 1st part)
Ascending + Descending Colon
IVC
Aorta
Vagina
Rectum
Parotid Gland:
i) Surface Markings
ii) Innervation
iii) Structures passing through: Superficial to deep
iv) Causes of parotid gland swelling?
v) Which muscle does the Zygomatic Branch of CNVII Supply?
i) Superior- From tragus of ear forward to zygomatic arch.
Medial - From zygomatic arch arches down towards angle of mandible
Posterior / Lateral - Ascends wrapped around angle of mandible.
ii) Innervated by Auriculotemporal Nerve (V3) –> The branches orginiate from CN IX (PNS)
iii) SUP: CNVII, Retromandibular Vein (formed from max. vein + sup. temp. vein), External Carotid.
iv) Mechanical - Stones, Obstructed Duct. Infection- Mumps, bacteria, TB. Neoplasm. Autoimmune- Sjogrens, SLE, Sarcoid. Drug - Antipsychotics
v) CNVII Zyg. supplies Orbicularis Oculi
Shoulder:
i) Ligament between Coracoid Process + Clavicle?
ii) Tendon responsible for Supraspinatous Impingement?
iii) What type of joint is the sternoclavicular joint?
iv) Nerve supply of rhomboideus
v) Action of Serratus Anterior
i) Coracoclavicular Ligament - Has two portions: Conoid and Trapezoid ligaments
ii) Coracoacromial ligament
iii) Atypical Synovial - has a disc but also partly resembles ball and socket
iv) Rhomboids - Dorsal Scapular Nerve ( C5 Nerve Root)
v) Serratus anterior - Lateral rotation/ protraction of scapula (C5-C7 Roots)
Axillary Artery:
i) Boundaries
ii) Branches
i) Proximal - Lateral border of first rib.
Distal - Inferior border of teres major
ii) Proximal to pec minor - Sup. Thoracic
Posterior to pec minor - Thoracoacromial, Lat. Thoracic
Distal to pec minor - Subscapular., P+A circumflex
Boundaries/ Transmits:
i) Quadrangular Space
ii) Triangular Space
iii) Triangular Interval
i) Quadrangular Space:
Sup- Teres Minor/ Subscapularis
Inf- Teres Maj.
Med- Long Head Triceps
Lat - Humerus
Transmits - Axillary N. Post. Circumfl.
ii) Triangular Space:
Lateral- Long head Triceps
Sup. - Teres Minor
Inf. - Teres Major
Transmits- Circumflex Scapular Art.
iii) Triangular Interval:
Sup - teres major
Lateral- Lateral head tric.
Medial- Long head tricep
Transmits - Rad. Nerve + Profundi Brachii Art.
What attaches to:
i) Coracoid Process
ii) Supraglenoid Tubercle
iii) Infraglenoid Tubercle
iv) Acromium
v) Greater Tuberosity
vi) Lesser Tuberosity
(of the shoulder)
i) Coracoid Process (of the scapula palpable beneath the clavicle) - Short head biceps, Pec Minor, Coracobrachialis.
ii) Supraglenoid Tubercle - Long head biceps
iii) Infraglenoid tubercle - Long head triceps
iv) Acromion (Continuation of the spine of the scapula) - Deltoid + Trapezius
v) Greater Tuberosity - Supraspinatous, Infraspinatous, Teres Minor
vi) Lesser Tuberosity - Subscapularis
Where does serratus anterior attach?
Origin -
Attaches to the scalene tubercle of the first rib - which is medially located on the posterior upper sruface
and
1st - 9th Ribs via series of slips
Insertion -
Medial border of scapula (Superior / Middle / Inferior insertions)
i)What is it?
ii) How does it enter the abdomen?
iii) How do sympathetic nerves leave the trunk
i) Sympathetic Trunk:
ii) Descends through carotid canal forming a plexus on ICA passing anterior to the first rib.
Descends just lateral to the vertebral bodies and passes behind median arcuate ligament to enter abdominal cavity.
iii) Formation of plexuses surrounding arteries or hitching on spinal nerves
Thoracic Duct :
i) Lies anterior to?
ii) Drains into the?
iii) What else drains lymph
i) Thoracic Duct lies anterior to the sympathetic trunk on the left side.
Passes into the thorax at the t12 aortic hiatus
ii) It drains lymph beneath the diaphragm and the left thorax (L Jugular, Mediastinal and subclavian trunks).
Drains into the L Brachiocephalic vein
iii) The right thorax has an independent route of drainage int the R brachiocephalic vein
i) Describe the intercostal neurovascular bundle?
ii) Arterial supply to the posterior intercostal spaces?
iii) Arterial supply to the anterior intercsotal spaces?
i) Superior to Inferior:
Vein, Artery Nerve
On the underside of the superior rib inbetween the innermost and inner intercostal muscles
ii) 1st two - By the costocervical artery of the subclavian artery
Rest by the intercostal arteries (segmental)
iii) Internal Thoracic artery of the subclavian artery (supplies breasts too)
i) Innervation of Anterior body of digastric muscle?
ii) How is the submandibular gland related to thy mylohyoid muscle?
iii) Describe route of Wharton’s Duct? what nerves are closely related to it?
iv) Nerve at greatest risk during submandibular gland surgery?
i) Mylohyoid nerve - Which is a branch of the inferior alveolar nerve (V3)
ii) Surrounds the muscle. Bulk is superficial to the muscle but there is a smaller portion deep to it
iii) Wharton’s Duct - Lies in between Mylohyoid (superficial to it) and Hypoglossus (Deep to it) and opens either side of the lingual frenulum
Lingual nerve and hypoglossal nerve are in close proximity.
iv) Marginal Mandibular Nerve - incision 2.5cm inferior to the mandible
i) Cardiac Surface Markings
ii) Anterior Surface of Heart
iii) Possterior Surface of Heart
Chest X Ray Cardiac Anatomy
iv) Right Lower Parasternal
v) Left Heart Border
i) Superior - 3rd Rib at Right Parasternal/ 2nd Rib at Left Parasternal
Inferior - 5th ICS Left Mid Clavicular Line/ 6th ICS Right Parasternal
ii) Anterior - Right Atrium + Right Ventricle
iii) Posterior - Left Atrium
iv) Right Atrium - Right Border of cardiac sillouhette
v) Left Ventricle - Left border of cardiac sillouhette
Surface Markings of the i) pleura
ii) Oblique Fisure
iii) Horizontal Fissure
i) Superior - 2.5cm above medial third of clavicle
Meet at sternum –> then 4th rib seperate
8th rib - Mid - Clavicular
10th rib - Mid - Axillary
12th rib - Posterior
Note - R side of pleura descends 6th parasternally before moving off midline /
whereas L Side of pleura descends 4th parasternally before moving off midline
ii) Oblique Fissure:
3rd thoracic spine posteriorly –> 6th Costocondral Junction ANteriorly
iii) Horizontal Fissure:
Oblique Fissure in mid axillary line –> Fourth Costal Cartilage (only on right)
Which Muscle:
i) Opens the vocal cords
ii) Close Vocal Cords
iii) Reduce Tension in the vocal cords
iv) Increase tension in the vocal cords
v) Name the strap muscles ( again ) and their innervation
i) Posterior Cricoarytenoid - Opens the vocal cords
ii) Lateral Cricoarytenoid - Close the vocal cords
iii) Thyroarytenoids - Reduce tension in vocal cord
iv) cricothyroids - Increase tension in vocal cord
v) Strap Muscles function to depress hyoid and larynx:
Ansa Cervicalis (C1-C3 originating from cervical plexus. Content of the carotid sheath) - Sternothyroid, Sternohyoid, Omohyoid
C1 - Thyrohyoid
Nerve supply to muscles of:
i) Larynx
ii) Pharynx
iii) Tongue
iv) Mastication
Describe the sensory and motor supply to the larynx
Sensory:
Internal Laryngeal Nerve - Sensation above vocal Cords
Recurrent Laryngeal Nerve - Sensation below vocal cords
Motor:
External Laryngeal Nerve- Cricothyroid
Recurrent Laryngeal Nerve - Everything else
Level of the :
Hyoid Bone
Thyroid Cartilage
Cricoid Cartilage
Hyoid Bone - C3
Thyroid Cartilage - C4
Cricoid Cartilage - C6
Note the cervical levels also correspond with which pharyngeal arch they originate from.
Parathyroid Glands:
i) Where are they found?
ii) Which pharyngeal arches do they come from?
iii) Blood Supply?
i) They are found posterior to the thyroid gland (two on each side)
ii) Superior Parathyroids - from the 4th Pharygneal Arch
Inferior Parathyroids - from the 3rd Pharyngeal ARch
iii) Blood supply is solely from the inferior thyroid artery
i) Urethral Sphincters:
Where are the locations and constituents
ii) Where do the ejaculatory ducts open
i) Internal urethral sphincter -
Continuous with bladder musculature. Continuous circular smooth muscles
External urethral sphincter -
Below the prostate in the deep perineal pouch.
Comprised of rectourethralis muscle + levator ani muscle
ii) Ejaculatory ducts open onto each side of the Prostatic utricle (blind ended pouch)
Layers of the scrotum
Skin
Subcutaneous Fascia
Dartos Fascia
External Spermatic Fascia
Cremasteric Fascia
Internal Spermatic Fascia
Tunica Vaginalis (pouch of serous membrane covering testicle. Vagination of the peritoneum. Remnant of the route of descent of testes - processes vaginalis )
Tunica Albuginea (fibrous covering of the testes)
Sensory Supply from Common peroneal nerve
Common peroneal Nerve - L4-S2
Sural Communicating Nerve - Aids the sural nerve. Posterolatearl leg
Lateral Sural Communicating Nerve - Upper Lateral Leg
Terminal branches:
Sup peroneal Nerve - Dorsum of foot
Deep Peroneal nerve - First Web Space
i) Level of CCA Bifurcation
ii) Where does ICA enter skull?
i) C4 - just inferior to hyoid bone
ii) Carotid Canal
Neurovascular supply of the penis
i) Arteries: Dorsal arteries, Deep Arteries, Bulbourethral Artery (all from internal pudendal artery)
ii) Veins: Superficial and Deep Dorsal Veins - Drain into the prostatic venous plexus
iii) Neves: Dorsal nerve of the penis (Pudendal Nerve) - Sympathetic and sensory
Peri-prostatic nerve plexus (parasympathetic)
Contents of Femoral Sheath
Femoral Artery
Femoral Vein
Femoral branch of the genitofemoral nerve
Lymphatics (+Lymph node of Cloquet)
Tensor Fascia Lata
i) innervation
ii) Origin and insertion
iii) Muscular attachments
i) Innervation - L5+S1
ii) Origin - Iliac Crest
Insertion - Iliotibial Band
iii) Acts synergistically with the - Gluteus Maximus, Gluteus Medius, Gluteus Minimus
Occulomotor nerve:
i) Arises from?
ii) Nucleus
i) arises from the superior colliculus of the midbrain
ii) Occulomotor Nerve Nucleus (superior colliculus of the midbrain) - PNS
Edinger Westphal Nucleus (Superior colliculus of the midbrain) - PNS
DIfference between carotid body and carotid sinus and aortic body
i) Carotid Body - is a chemoreceptor in adventitia of the bifurcation of CCA
- Responds to hypoxia, hypercapnea and increased pH –> Increased BP/HR + RR
- Has two cell types - Chief Cells + Substentacular Cells
ii) Carotid Sinus - Carotid bulb of internal carotid artery.
- Baroreceptor
iii) Aortic Body - Chemoreceptors present along the aortic arch
i)What is phimosis
ii) Causes of phimosis
i) Phimosis - Inability to retract foreskin over the glans.
ii) Mechanical - Narrow foreskin, Fusion of forekin with glans, Short frenulum
Inflammatory - Balnitis, Lichen Sclerosus or balanatis xerotica obliterans, repeated catheterisation
How is parotid gland innervated?
PNS - Otic Ganglion (Originally tympanic nerve [CN IX branch] –> form lesser petrosal nerve after tympanic plexus in middle ear –> go to otic ganglion —> Auriculotemporal Nerve to Parotid Gland )
SNS - Superior Cervical Ganglion
Sensory- Greater Auricular Nerve
Structures passing through parotid gland
Facial Nerve (Mandibular Nerve is well seperated from the gland)
Retromandibular Vein
Auriculotemporal nerve ( Branch of V3)
External Carotid Artery
innervation of submandibular gland
Arterial and Venous Supply
Lymph Drainage
Sympathetic - superior cervical ganglion
Parasympathetic - submandibular ganglion via lingual nerve
Arterial Supply - Facial ARtery
Venous Drainage - Anterior Facial Vein
Lymph - Deep Cervical + Jugular
Gland Innervation
Lacrimal
Submandibular/Sublingual
Parotid
What seperates the sublingual from the frenulum of the tongue
What seperated the submandibular and parotid gland
Lacrimal - Greater petrosla nerve (VII) to the pterygopalatine gaglion. Then lacrimal (V1) to the gland
Submandibular/Sublingual - Chorda Tympani (VII) to the lingual nerve (V3) to the submandibular ganglion
Parotid - Glossopharyngeal nerve (IX) to Leseer petrosal nerve –> Otic Ganglion –> Auriculotempral Nerve (V3)
Warton’s Duct/Lingual Nerve seperates the sublingual gland from the frenulum of tongue
The Stylomandibular ligament seperates the submandibular and parotid gland
Scalene Muscles:
Attachments
Innervation
What passes between
Anterior
Transverse spinous processes C3-C6 -> First Rib (Scalene Tubercle)
Innervated Anterior Ramiof C5 - C6
Anterior to Anterior Scalene - Subclavian Vein + Phrenic Nerve
Middle
Transverse spinous processes C2-C7 -> First Rib (Scalene Tubercle)
Innervated anterior rami of C3-C8
Between anterior and middle scalene - Subclavian Artery and brachial plexus
Posterior
Transverse spinous processes C5-C7 -> Second Rib
Innervated anterior rami of C6-C8
Ulna Claw
At the Wrist: (Guyon’s Canal)
Muscles affected - Medial two lumbricals, Adductor Pollicis, Interossei muscles
Claw - Hyperextension of MCPs, Hyperflexion of DIPs
At the elbow: (Cubital Canal)
Muscles affected - Lateral two lumbricals, adductor pollicis, itserossei muscles, Lateral, FDP, FCU (Variable)
Claw - Hyperextension of MCPs, The claw is often less severe as the FDP is not spared and therefore doesnt contribute to hyper flexion of the IPs.
Pelvis
i) Muscles of the lateral walls
ii) Muscles of the pelvic floor
iii) What consitutes the levator ani?
i) Piriformis + Obturator Internus
ii) Pelvic Floor Muscles - Levator Ani, Coccygeus
iii) Levator Ani is made up of 3 distinct muscles (innervated by Pudendal Nerve):
Puborectalis (+prerectal fibers) - Pubic Bones past the urogenital hiatus to the rectal hiatus which it surrounds. Prerectal fibers are very important in maintaining urinary continence
Pubococcygeus - Immediately lateral to puborectalis. Arise from pubic bones and attach to the coccyx/anococcygeal ligament
Iliococcygeus - from ischial spines to coccyx/anococcygeal ligament
Median Nerve Claw
Supra-Elbow - Hand of Bennediction (On trying to make a fist)
Intrinsic hand muscle loss: Loss of thumb opposition/ Abduction/ Lateral two lumbricals/ Flexor pillicis brevis
Loss of Pronation (with arm extended) + Loss of wrist flexion
Appearance - Hand of bennediction - on trying to make fist the Lateral three digits are un able to flex due to loss of FDP, FDS.
Ape Hand - This refers to the adducted thumb position resultant throm loss of abductor pollicis longus and wasted thenar aminence
Which pharnygeal arches are the following structures derived from:
Superior parathyroid glands
Inferior parathyroid glands
Superior - Fourth Pharyngeal Arch
Inferior - Third Pharyngeal Arch
Nerves associated with pharyngeal arches
I - Trigeminal
II - Facial
III - Glossopharyngeal
IV - Vagus
VI - Vagus + RLN
Coccygeus
Insertion / Attachment
Innervation
Coccygeus
Ischial Spines –> Lateral Sacrum, Coccyx, Sacrospinous Ligament
Innervation - Anterior Rami of S4+S5
i) Anatomical Borders of the perineum / Surface borders
ii) Anal Triangle Contents
i) Anatomical
Anterior - Pubic Symphsis Posterior - Coccyx
Lateral - Inferior Ischial + Pubic Rami, Sacro tuberous ligament
Roof - Pelvic Floor Floor - Skin and fascia
(Divided into urogenital and anal triangless by a line through the ischial tuberosities)
Surface
Anterior - Mons Posterior - Intergluteal cleft Lateral - Medial thigh
ii) Anal Orifice, External Anal Sphincter, Ischioanal fossae (either side of anal orifice inferior to pelvic diaphragm )
What is in the epidural space?
Dural Venous Sinuses
Spinal nerve roots
connective tissue
Urogenital Triangle:
i) Layers + their contents
ii) What goes the perineal membrane?
i) Deep Perineal Pouch - Between the pelvic floor (deep) and the perineal membrane (superficial)
Men - Urethra, External urethral sphincter, bulbourethral glands, transverse perineal muscle
Women - Urethra, External urethral sphincter, vagina
Superficial Perineal Pouch - Between the perineal membrane (deep) and the Deep perineal “Colles’” fascia (superficial)
Laterally - Corpus Cavernosus (Crus of clitoris/penis), Medially - Corpus Spongiosum. Ischocavernosus, Bulbospongiosus, Superficial Transverse perineal muscle.
ii) In women - the vagina and ureter go through the perineal membrane
How does the pundendal neurovascular bundle reach target organs?
Pudendal Nerve + Internal Pudendal Artery
Course along the ischial tuberositeis within a thickening of obturator fascia called “Alcock’s Canal”.
Then travels through each Ischioanal fossa (lateral to the anal orifice between the pelvic diaphragm and skin)
What is the perineal body?
It is an irregular fibromuscular mass acting as a point of attachment for various structures.
Location - Junctional between urogenital and anal triangles.
Attachments -
Levator Ani
Bulbocavernosus
Transverse perineal muscles (deep+superficial)
External Anal Sphincter
Internal Anal sphincter
Arteries in the foot
Dorsalis Pedis (From the Anterior Tibial Artery)
- Enters the foot anteriorly over the tarsal bones then moves inferiorly to the sole anastamosing with the lateral plantar artery
Posterior Tibial Artery
- Enters sole of foot through tarsal tunnel and contributes to medial and lateral plantar artery
Deep Plantar Arch - gives off common plantar digital arteries to the digits
Derived from both medial and lateral plantar artery.
Medial plantar artery also provides plantar digital artery to the hallux.
Lateral plantar artery also proves plantar digital artery to the fifth toe
What is the portal triad
Portal Venule, Hepatic Arteriole + Bile Duct
What level does the pulmonary trunk divide?
How many cusps does the pulmonary valve have?
What is the pulmonary ligament
Most anterior structure in hilum?
What level does the pulmonary trunk divide?
T5
How many cusps does the pulmonary valve have?
3- Anterior, Left + Right
What is the pulmonary ligament
Sheet of parietal + Visceral pleura extending from the medial surface of the lower lobe to the mediastinum just inferior to the hilum
- Allows expansion of hilar vessels in times of increased cardiac output
Structures of the hilum:
Vein is most anterior
i) Attachments of the diaphragm
ii) What structures run through central tendon of diaphragm
iii) Through which ligament does the porta hepatis run?
iv) Boundaries of the quadrate lobe?
i) Xiphisternum
7-12th Ribs
Lumbar Vertebrae (left and right crura)
Central Tendon - Attached to the fibrous pericardium
ii) Central Tendon: IVC + R Phrenic Nerve
iii) Hepatoduodenal ligament contains the porta hepatis
iv) Quadrate Lobe:
R- Gallbladder Fossa
L- Umbilical Vein Fossa
Posterior - Porta Hepatis
What is the arcuate line?
The arcuate line is a:
Horizontal line 1/2 been umbilicus and the pubic crest.
Demarcates the end of the posterior rectus sheath + where the inferior epigastric vessels perforate the rectus abdominus
Above the arcuate line:
Anterior Rectus Sheath - External oblique aponeruosis + Anteria lamina of internal oblique aponeurosis
Posterior Recuts Sheath - Posterior lamina of internal oblique aponeurosis + tranverses abdominus aponeuoriss
Below the arcutate line :
Anterior REctus sheath - combination of EOA, IOA + TAA
Behind this the rectus abdominus is in direct contact with the transversalis fascia
Innervation:
i) Of the colon
ii) Of the small intestine
i) Midgut Derived Structures:
Superior Mesenteric Plexus - Approximates well to the SMA –> axxompanying it into the mesentery where it divides to give secondary plexi.
It is a continuation of the coeliac plexus (Receives an extra branch from the R Vagus)
Hindgut derived Structures:
Inferior Mesenteric Plexus :
PNS - Pelvic Splanchnic Nerves
SNS - Lumbar Splanchnic Nerves
ii) Coeliac plexus - From the greater + lesser splanchnic nerves and anterior and posterior vagal trunks
—> gives off hepatic, pancreatic, splenic, gastric, suprarenal plexi, renal, gonadal and superior mesenteric plexus.
Tributaries to the IVC
Distal -> Proximal
L5 - Two CIV Join
L5- Median Sacral Vein
L5-L3 - Lumbar Veins
L3 - Right Gonadal Vein
L2 - Renal Veins
L2/L1 - Right Suprarenal Vein
T12 - Inferior Phrenic, Left/Middle/Right Hepatic Veins
Adrenal Gland Blood Supply
Arterial:
Superior - Inferior Phrenic
Middle - Abdominal Aorta
Inferior - Renal Artery
Venous:
Left Adrenal Vein –> Renal Vein –> IVC
Right Adrenal Vein —> IVC
Sympathetic Trunk:
i) Extent
ii) How does it communicate with spinal nerves?
i) Extends from T1-L2
ii) Communicates with spinal neves through rami communicantes
Duodenum:
i) What is behind first part
ii) What is behind third part
iii) What is in front of third part?
iv) Behind fourth Part?
i) Behind 1st/2nd Part - Gastroduodenal Artery
ii) Behind 3rd Part - Aorta / IVC
iii) Anterior to third part - SMA / SMV
iv) Behind Fourth Part- Left Renal vein
i) Where do you find diploic veins?
ii) Arterial supply to temporalis muscle?
iii)
i) Diploic veins are found in between the inner and outer layer of cranial bones and drain into the various intracranial sinuses
ii) Deep temporal artery - Branch of maxillary artery
i) Thoracic Duct Drains into
ii) Azygos Vein drains into
i) Thoracic Duct Drains into the left subclavian vein (Croses behind the oesophagus from right to left at the vertebral level T4)
Right Thoracic Duct/ Subclavian Duct/ Jugular Duct all drain into the Right subclavian vein
ii) Azyguos Vein Drains into the Superior Vena Cava
Small Cardiac Vein Runs with..
Middle cardiac Vein runs with ..
Great Cardiac Vein runs with ….
Small Cardiac Vein - Right Coronary Artery
Middle Cardiac Vein - Posterior Interventricular Artery
Great cardiac vein - Anterior Interventricular Artery
Hip:
1) Origin of vastus muscles?
2) Origin / Insertion of short external rotators?
1) Vastus Muscles (Med, Intermedialis, Lat) all originate from the
intertrochanteric Line
Lat- Superiorly
Medialis - Inferiorly
Interm - In between
2) OSIQ
Oburator Internus
Superior Gemellus
Inferior GEmellus
Quadratus Femoris
all originate from the Ischial Tuberosity in that order
and insert onto the greater trochanter
What is meant by the extensor expansion?
The Extensor Digitorum Tendons:
- Flatten as they reach the metacarpophalangeal joints forming a hood
and then
Medial Band attaches to the middle phalanx
Two Lateral Bands attach to the distal phalanx
Function - compound tendinous attachment for the extensor digitiorum, lumbricals and interossei muscles
What is a GIST?
Malignant potential?
How is TK Involved?
A tumour of mesenchymal origin
- arising from smooth muscle pacemaker cells of kajal
Mutations in the KIT gene
They have a low malignant potential compared to other GI tumours
KIT - encodes a Tyrosine Kinase like transmembranous receptor:
- Leads to phosphorylation of ADP
–> In turn leading to various effects acting like and on/off switch —> Enzyme changes, Cellular proliferation signalling.
Pectoralis Major Components + Functions
Interbercular Groove –> Clavicle + Sternum
Clavicular - Flexion
Sternum - Adduction
Also accessory muscle of inspiration
Relations of pancreas
Superior - Splenic ARtery
Inferior - Third part of duodenum, DJ Flexure
Anterior - Stomach, Gastro duodenal artery (to head)
Posterior to body - SMA, AOrta,
Posterior to neck - IVC SMV
How do middle ear infections cause intracranial probelms
Through Mastoid Air Cells causing local bony erosions.
OR
Cholesteatoma leading to bone erosion
Temporal Abscess / Meningitis
Sigmois Sinus Thrombosis
